Political Anatomy of The Body Medical KN

Political anatomy of the body
Medical knowledge in Britain in the twentieth century

Political anatomy
of the body
Medical knowledge in Britain
in the twentieth century
DAVID ARMSTRONG
Guy's Hospital Medical School
CAMBRIDGE UNIVERSITY PRESS

Cambridge
London New York New Rochelle
Melbourne Sydney
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© Cambridge University Press 1983
First published 1983
Printed in Great Britain at

the University Press, Cambridge
Library of Congress catalogue card number: 82-9546
British Library cataloguing in publication data

Armstrong, David
Political anatomy of the body.
i. Social medicine - Great Britain
I. Title
362. i'0941 RAîS
ISBN o 521 24746 2
for Pauline
Contents
Acknowledgements ix
Preface xi
1 The clinical gaze i
2 The new hygiene of the Dispensary 7
3 Invention of the neuroses 19
4 A medicine of the social 32
5 Technologies of the survey 42
6 Disciplines of the survey: i. child life and health 54
7 Disciplines of the survey: 2. psychiatry 64
8 Disciplines of the survey: 3. general practice 73
9 Disciplines of the survey: 4. geriatrics 85
10 A community gaze 93
11 Subjective bodies 101
12 Postscript: the human sciences 113
Notes 118
Index 145
Acknowledgements
I am grateful for the guidance and encouragement of Margot Jefferys who

acted as my supervisor for the thesis on which this book is based. I am also
indebted to those many colleagues within medical sociology who have
made helpful comments on the various papers and drafts which have gone
to make up the final work. Perhaps I should mention in particular the
valuable critical points made by Bill Arney, Robert Dingwall, Gordon
Horobin and Peter Miller.
My thanks are also due to Carol Butterfield who did all the typing with
her usual skill and forebearance, and to Cambridge University Press,
particularly Sheila Shepherd for valuable editorial help.
Preface
I doubt if it ever occurred to me or my fellow medical students that the

human body which we dissected and examined was other than a stable
experience. It was therefore with considerable surprise that years later I
learned that it was only since the end of the eighteenth century that disease
had been localised to specific organs and tissues, and that bodies had been
subjected to the rigours of clinical examination.
At first it seemed strange to me how the apparent obviousness of disease
and its manifestations inside the body had eluded scientific discovery for so
long. How had pre-Enlightenment generations failed to see the clearly
differentiated organs and tissues of the body? Or failed to link patient
symptoms with the existence of localised pathological processes? Or failed
to apply the most rudimentary diagnostic techniques of physical examina-
tion? My disbelief grew until it occurred to me that perhaps I was asking the
wrong questions: the problem was not how something which is so obvious
today had remained hidden for so long, but how the body had become so
evident in the first place. In dissecting and examining bodies I had come to
take for granted that what I saw was obvious. I had thought that medical
knowledge simply described the body. I argue in this book that the
relationship is more complex, that medical knowledge both describes and
constructs the body as an invariate biological reality.
It was the work of Michel Foucault which offered me a means of grasping
the relationship between medical knowledge and its object, the body. For
Foucault, the concept of the body which emerged at the end of the
eighteenth century-discrete, objective, passive, analysable-was the effect
as well as the object of medical inquiry. The first chapter of this book
attempts to set out more fully Foucault's arguments, particularly as they
pertain to events during the late eighteenth century: I hope that I have
neither over-simplified nor misreported. I should, however, point out that
Foucault's evidence is drawn primarily from French sources and many of
the changes he documents - such as the emergence of individualism - may
have occurred over a longer time period in the Anglo-Saxon world.
Nevertheless, I remain impressed with the general thrust of his argument
xii Preface
and the details of his method, and there seems little doubt, at least so far as
medicine is concerned, that Parisian hospitals at the end of the eighteenth
century formed the epicentre of a medical revolution.
Following this introductory chapter the book deals almost exclusively
with medical writings in Britain in the twentieth century and pursues an
argument that this period has witnessed a further fundamental reformula-
tion of the nature and identity of the human body. Chapters 2, 3 and 4 deal
with events prior to World War n: chapter 2 develops the general model I
employ, while chapters 3 and 4 offer, in the development of the neuroses
and of social medicine, particular illustrations. Chapter 5 outlines the
development of the survey as a medical technique during the war years, and
the following five chapters cover the post-war emergence of the disciplines
of paediatrics, psychiatry, general practice, geriatrics and community
medicine. The penultimate chapter, through a documentation of the
doctor-patient relationship during the period, attempts to show how these
various medical events have served to fabricate, not, as in the nineteenth
century, a discrete, passive, physical body, but an essentially relative and
subjective one.
I might add that while the book deals with medical knowledge in the
twentieth century it is not meant to be a history of events. I am trying to deal
with what Foucault terms 'conditions of possibility' I am therefore not
concerned with whether the medical perceptions which I document were in
any sense correct or typical but rather at what point a thought became
thinkable. I hope therefore that the argument of the book is applicable
outside the narrow geographical confines of Britain. To this end, in the final
chapter - which acts as a postscript to the general thesis - I have tried to
show the parallel points in the human sciences, as they developed in the
Anglo-Saxon world during the twentieth century, when particular techni-
ques, approaches and knowledges of the body became possible.
1
The clinical gaze
For us the human body defines, by natural right, the space of origin and
of distribution of disease: a space whose lines, volumes, surfaces, and
routes are laid down, in accordance with a now familiar geometry, by the
anatomical atlas. But this order of the solid, visible body is only one way-
in all likelihood neither the first, nor the most fundamental - in which one
spatializes disease. There have been, and will be, other distributions of
illness.
Michel Foucault: The birth of the clinic1
The anatomical atlas stands between ignorance and medical knowledge.

By means of the atlas a confusing mass of cells, tissues and organs is given a
pattern: specific structures are indicated by means of arrows and labels, the
relationships between organs and tissues are made clear by the use of
different colours and the great systems of the body are identified by
overlying transparencies. With the aid of these various techniques of
illustration the atlas depicts the organisation and solidity of the three-
dimensional body on the two-dimensional page; it enables the interior of
the body to be differentiated and deciphered to the point at which an
observer is able from the outside without dissection to read the internal
structures and their changes. The atlas renders the body transparent, it is a
means of making the body legible to an observing eye.
There was a time of course, before the atlas, when the body could not be
read with such clarity. It was not that the body was illegible, more that
there were different languages by which it was read - those of the soldier,
the astrologer, the lay healer (many undoubtedly never committed to
paper). Foucault, for example, describes an eighteenth-century French
physician who treated a hysteric by making her take frequent baths and
then reported seeing 'membranous tissues like pieces of damp parchment
... peel away with some slight discomfort, and these were passed daily with
the urine', or the intestines 'peeled off their internal tunics, which we saw
emerge from the rectum'. 2 In terms of the twentieth-century anatomical
atlas which informs the gaze deep into the body such observations are
virtually unintelligible because, at the moment the modern atlas made its
2 Political anatomy of the body
appearance, the old languages, the ancient ways of seeing, disappeared. In

their place came a more penetrating gaze that used the new techniques of
observations, palpation, percussion and auscultation and made the deepest
recesses of the body transparent to the medical eye.
The fact that the body became legible does not imply that some invariatc
biological reality was finally revealed to medical enquiry. The body was
only legible in that there existed in the new clinical techniques a language
by which it could be read. The anatomical atlas directs attention to certain
structures, certain similarities, certain systems, and not others and in so
doing forms a set of rules for reading the body and for making it intelligible.
In this sense the reality of the body is only established by the observing eye
that reads it. The atlas enables the anatomy student, when faced with the
undifferentiatcd amorphous mass of the body, to see certain things and
ignore others. In effect, what the student sees is not the atlas as a
representation of the body but the body as a representation of the atlas.
The atlas is therefore a means of interpreting the body, of seeing its form
and nature and establishing its reality. The modern body of the patient,
which has become the unquestioned object of clinical practice, has no social
existence prior to those same clinical techniques being exercised upon it. It
is as if the medical gaze, in which is encompassed all the techniques,
languages and assumptions of modern medicine, establishes by its
authority and penetration an observable and analysable space in which is
crystallised that apparently solid figure which has now become so familiar
the discrete human body.
The analysis of the way the body is seen, described and constructed,
Foucault suggests, might be called 'political anatomy'.3 It is political
because the changes in the way the body is described are not the
consequences of some random effects or progressive enlightenment but are
based on certain mechanisms of power which, since the eighteenth century,
have pervaded the body and continue to hold it in their grasp. From that
time the body has been the point on which and from which power has been
exercised.
Mechanisms of power
Towards the end of the eighteenth century medical men started to subject
their patients to physical examination. The basis of this change in medical
procedure was the newly discovered pathological anatomy by which
diseases became localisable in the body of the patient: in place of the
constantly shifting symptoms in the patient's history medicine pin-pointed
pathology in the interior of the body and used the ever more detailed
methods of the examination to diagnose it. Contemporaneously a change
The clinical gaze 3
occurred in the regime of criminal punishment: from being subjected to

torture, pillorying and public display the criminal became incarcerated and
subjected to continuous surveillance behind the high walls of the prison.
Foucault argues that these changes in the way the body was treated were
not coincidental but reflected a new political anatomy: 'the classical age
discovered the body as object and target of power'. 4 Throughout European
society during this period the body became treated 'as something docile
that could be subjected, used, transformed and improved' The body
became surrounded and invested with various techniques of detail which
analysed, monitored and fabricated it. Architectural space became gov-
erned by the need to assign particular places to particular individuals (and,
conversely, individuals to particular places). The individual was no longer
placed in a fixed social place but in a rank which stressed relations of
positions. Bodily activities were temporally ordered. The timetable, for a
long time used in monastic communities to preclude idleness, was more
widely introduced to establish rhythms, impose particular occupations and
regulate the cycles of repetition in schools, workshops, prisons and
hospitals. These different ways of seeing bodies served to establish a true
political economy of the corporal in which time, detail and gesture were
broken down into their component parts, analysed and reconstituted to
exact from coordinated and disciplined bodies more than the sum of their
separate contributions.
These various techniques of analysis that invested the body all involved
surveillance: bodies had to be inspected to judge their status, they had to be
analysed to identify their deficits and they had to be monitored to evaluate
their functioning. The importance of surveillance is illustrated in particular
in the various techniques of examination that emerged to prominence in the
eighteenth century such as the clinical examination in the hospital, the
inspection in the prison, the test in the school and the military inspection in
the barracks. Together, these procedures served to ensure that the person
under observation was the object of a detailed analysis.
Foucault suggests that these various techniques represented different
aspects of a disciplinary apparatus. Discipline involves attention to fine
detail, to strict monitoring and to the object of the disciplinary regime - the
individual body - being trained to function with coordination and
efficiency: through discipline, surveillance fabricates a manipulable body.
Discipline is a mechanism that invests the body of whoever is observed,
transforming an unorganised and incoherent being into an efficient
structure. The army, for example, took untrained bodies and, through
analysis of bodily movements in the routines of drill or the regular
surveillance of parade-ground inspections and hierarchies of observation,
succeeded in creating a disciplined soldier. The disciplinary apparatus was
a creative technology which served to fabricate discrete individuals. The
late eighteenth century saw the separate analysis and documentation of the
body, from the case history in medicine to the appearance of ordinary
people, in that new literary form, the novel; it was also marked by the first
appearance of the word and notion of'individualism'.
The observer, who through surveillance functioned to fabricate these
individual identities, was neither unique nor important. Discipline
depended not so much on a person as on an observing gaze. It mattered
little who the observer was, more that he functioned as a component in a
unified observation. 'The perfect disciplinary apparatus', Foucault notes,
'would make it possible for a single gaze to see everything constantly.' The-
configuration of power in a disciplinary regime was simply the relationship
between an individualised body and a disembodied gaze. Power, in this
sense, is not a thing, it is not something that is 'acquired, seized or shared,
something that one holds on to or allows to slip away'. 5 Power is simply a
shorthand for describing a certain 'strategic relation' in a given society.
Thus power in the hierarchised surveillance of the disciplinary techniques
'functions as a piece of machinery. And, although it [has] a head, it is the
apparatus as a whole that produces "power" and distributes individuals in
the permanent and continuous field.'
Under the old regime the mechanism of power was represented by
sovereignty in which the population was subjected to the 'spectacle of
power'. Sovereignty functioned through being visible to those on whom it
had its effects: the royal presence was signified by outward shows of
ostentation, the ceremony and the ritual, palaces, processions, public
displays and marks of allegiance. In contrast, disciplinary power inverted
the principle of visibility; it required, not the visibility of itself, but of its
target - and that target was the individual body which became at the same
time both object and effect of the disciplinary gaze. There had of course
been 'individuals' in previous societies but, in that they emerged under a
regime of sovereign power, they had been marked out by privilege, ritual,
heroics and ceremonies. In the disciplinary regime, on the other hand,
individualisation commenced at the 'bottom' bringing 'ordinary individu-
ality - the everyday individuality of everybody - [from] below the threshold
of description'.
With the new 'micro-physics' of power, in which the individual body
became the target and effect of a ubiquitous and calculating gaze, the field
of knowledge and human understanding was reformulated. It became
possible to imagine a docile workforce, a disciplined army, a growing child
and a medicine that analysed and investigated bodies. The ordinary
individual emerged in, and was fabricated by, the discourse of the age; and
the study of the individual in the form of the human sciences became a
possibility.
The clinical gaze 5
Panopticism
Foucault suggests that the particular configuration of an individuated,
analysed body and a disembodied gaze found its near-perfect representa-
tion in Bentham's plans for an ideal prison, the Panopticon. The design of
the Panopticon was of a building arranged as a ring, at the centre of which
was a tower. The peripheral building was divided into cells; each cell had
two windows, an outer one to allow light to fall on the inmate and an inner
one to allow a guard in the central tower to observe the inmate's actions.
The central tower was pierced by large windows opening onto the inner side
of the peripheral ring. These windows allowed the guard full visibility of the
prisoners but because they were also shuttered they prevented the prisoner
being aware of when and by whom he was being observed. Each cell was
thus 'like so many cages, so many small theatres, in which each actor is
alone, perfectly individualised and constantly visible'.
As disciplinary power spread throughout European society at the end of
the eighteenth century the Panopticon served as an architectural model for
all those agencies which sought to analyse and improve the efficiency of
individual bodies. New institutions emerged with high external walls -
schools, hospitals, barracks, prisons and workshops - but whose internal
arrangements permitted constant visibility of their inmates to an ever-
probing gaze. 'The crowd, a compact mass, a locus of multiple exchanges,
individualities merging together, a collective effect is abolished and
replaced by a collection of separate individualities.'
The panoptic vision was not simply a technique by which those in
authority could repress a population; nor can it be analysed in terms of the
'social control' of those deviants and outcasts of capitalist society who
threatened to undermine the social order. The Panopticon was not a dream
building in which men and women were enslaved but 'the diagram of a
mechanism of power reduced to its ideal form'. To see the Panopticon as an
institution of repression is to treat power as something that forbids and
alienates. The Panopticon represented a creative arrangement of power
which fabricated an individual body - that very body which was to be the
point on which repression could be exercised and into which ideologies
could be inscribed, but, nonetheless, a body which had no existence prior to
its crystallisation in the space delineated by a monitoring gaze.
In part, because panoptic surveillance works through a system of
'inverted visibility', the nature of power, of its basis in an ideal optical
arrangement, has tended to remain hidden and even concealed. Thus the
anatomical atlas, for all its short history, would claim that the body which it
describes is a universal and fixed biological entity. Even those disciplines
which would disclaim a biological basis still accept the a priori existence of
an individualised analysable body. Yet, within the discourse of all these
various disciplines of the individual, there lies an imprint of a body which

was at the same time both the object of analysis and its effect.
It is apparent, as Foucault observes, that late in the eighteenth century
medicine began to see a body which had a new anatomy. This body appears
to have been discrete because it was recorded in separate case notes; it was
accessible because at this time medicine began to use methods of physical
examination; it was analysable because pathology became localisable to a
distinct point within the body; it was passive because the patient's personal
history was relegated from its primary position as the key to the diagnosis to
a preliminary; and it was subjected to evaluation because patients were
moved from the natural locus of the home to the neutral domain of the
hospital. Thus, every time medicine had cause to deploy its new techniques
and treat an illness, it drew an outline of a particular anatomy, a docile
body. At first the procedure was unsure and the outline hazy but with time
and with refinement the shape became more clear. As the nineteenth
century progressed each and every consultation of the new pathological
medicine functioned to imprint, by its sheer repetition, the reality of a
specific anatomy on a social conscience.
In a sense the true inheritance of this period is the anatomical atlas which
proclaims on every page the solid, invariate reality of the body. Armed with
this truth it becomes possible to view the events of the late eighteenth
century as enlightenment: the abandonment of old superstitions, the
laying to rest of moral qualms about the post-mortem and physical
examination of the body, the brilliance of scientific advance, the techno-
logical breakthrough of the hospital. But there remains another anatomy
whose truth is not to be discovered in the bright illumination of the
dissecting room but in the dusty texts of forgotten knowledge. Therein lies
the outline of a body that was not fashioned long ago in an East African rift
valley but relatively recently in a medical gaze; a body that became
intimately legible at the end of the eighteenth century, a body whose reality
and transparency was consolidated in the nineteenth century, a body whose
existence gave rise to and was sustained by myriad techniques ranging from
the laws of cellular function to the great strategies of liberalism and
individual contract.
In the twentieth century the diagram of power is rearranged. The
medical gaze, which had for over a century analysed the microscopic detail
of the individual body, began to move to the undifferentiated space between
bodies and there proceeded to forge a new political anatomy.
The new hygiene of the Dispensary
In 1887, following the failure of the citizenry of Edinburgh to found a

special hospital for tuberculosis, Dr Robert Philip opened a tuberculosis
dispensary in Bank Street. In part, this dispensary functioned as an
out-patient clinic to which patients with tuberculosis were referred for
treatment; but it also arranged for a staff of nurses to visit the homes of
patients so as to discover their needs, to report on their circumstances, to
act as a conduit for charitable agencies, to report on contacts and to teach
the healthy way of life. With all this activity the dispensary 'came to
resemble the committee rooms of a general election where information is
collected and distributed, work arranged and timorous supporters stimu-
lated to duty'. 1
The Edinburgh dispensary prospered and the idea spread. A Central
Fund for the Promotion of the Dispensaries System was formed and started
operating tuberculosis dispensaries in London in 1911. The Departmental
Committee on Tuberculosis, established in the wake of the 1911 National
Health Insurance Act, officially endorsed the concept and suggested that
metropolitan borough councils should run and coordinate the growing
number of privately sponsored dispensaries. 2 The Departmental Commit-
tee argued that the dispensary should be a model for the care and treatment
of tuberculosis patients in as much as it offered a complete service. The
dispensary was a receiving house and centre of diagnosis; besides
confirming established cases of tuberculosis it could screen patients with
comparatively slight symptoms and act as the point at which apparently
healthy persons who had been in close association with a tuberculous
patient could be assembled and examined. The dispensary was a clearing
house and a centre for observation from which patients could be directed to
the most suitable place, home, hospital or sanatorium. Finally, the
dispensary was also a treatment centre for ill patients: a point at which
treatment was administered and from which treatment was monitored. In
effect, the dispensary was 'the centre from which the manifold activities
which safeguard the life of the sick person may be expected to radiate, and a
bureau of research, information and education'. 3
An extended medical gaz.e

The dispensary, of course, was not a new means of delivering health care;
dispensaries had existed for centuries as means of providing treatments and
advice for the poor. Yet in its old form the dispensary was a single immobile
point at which medical assistance could be obtained, whereas the new
dispensary, as founded in Edinburgh, represented a much more radical
arrangement.
The new dispensary was a building, but also a new perceptual structure
a new way of seeing illness which manifested itself in different ways.*
First, and most apparent, it was a new way of organising health care, of
effecting its geographical distributions. Whereas the hospital and out-
patient clinic had operated more or less within their own walls, the
dispensary radiated out into the community. Illness was sought, identified
and monitored by various techniques and agents in the community; the
dispensary building was merely the coordinating centre.
The need to establish a community presence arose from the new
distributions of illness. Traditional hospital medicine, which had emerged
at the end of the eighteenth century, had defined illness in terms of specific
pathological lesions located within the confines of the body and the medical
gaze aimed to observe the map through signs and symptoms the course
of the disease within the space of the body. 4
The new gaze, however, identified disease in the spaces between people,
in the interstices of relationships, in the social body itself. In this new
conceptualisation pathology was not an essentially static phenomenon to
be localised to a specific point, but was seen to travel throughout the social
body, appearing only intermittently. There was therefore a need for an
organisational structure which could both survey and constantly monitor
the whole community. Hence, also, the emphasis on close scrutiny of details
of patients' contacts and relationships, and the creation of a thorough
record of family networks, friends and acquaintances through which to
coordinate home-visits, checks and follow-ups.
In effect, the Dispensary involved a double mapping of locality and
relationships. The disease was geographically pin-pointed in the commun-
ity ('a red mark on a map for every case') - as it had been during the great
epidemics of the nineteenth century - so that its patterns and movements
could be observed and interpreted. Superimposed on this geographical
outline was the map of the social body on which, through screening and
observation of patient contacts, a network of social relationships could be
plotted. Gradually, as surveillance of patient contacts increased, the
* Hereafter I use the term 'dispensary' to refer to the traditional building and 'Dispensary' to
embrace this new way of construing illness.
The new hygiene of the Dispensary 9
medical gaze began to focus with greater intensity on the potentially ill: the
healthy and the normal.
In part, the Dispensary represented the Panopticon writ large, a whole
community 'traversed throughout by heirarchy, surveillance, observation,
writing'. 5 In this respect the Dispensary, as the Panopticon, had as its ideal
project the town in the grip of plague, sub-divided, analysed, monitored,
supervised, presenting a Utopia of efficient social management and
organisation. Yet there was also, as Foucault points out, another method of
exercising power over men, 'of controlling their relations, of separating out
their dangerous mixtures' This was to be found in the image of the leper
who gave rise to rituals of exclusion and, instead of the subtleties of multiple
partitions and organisation in depth of surveillance and control, a massive
binary division between one set of people and another.
In the nineteenth century both modes of control, multiple partitioning
and binary separation, coexisted. Binary separation in the form of the
mad/sane and the ill/healthy had its basis in the normal/abnormal
dichotomy which had emerged in the mid eighteenth century. Yet within
this bisected space the mad and the ill were subjected to the more
sophisticated analyses of disciplinary partitioning in which the abnormal
were separated out by diagnostic category and subjected to the surveillance
techniques of a panoptic apparatus. The Panopticon itself was a mechan-
ism of discipline and could, in principle, have been fixed on normal,
abnormal or whole populations. However, during the nineteenth century,
panoptic power was reserved primarily for the analysis of abnormal groups,
in part as an attempt to use its corrective features to reform deviant bodies.
The Dispensary was, on the one hand, an extension of the panoptic vision
to a whole society; on the other hand, its principle difference was its denial
of the rituals of separation and exclusion that had characterised the exercise
of panoptic power. In that the Dispensary required the social body to be
monitored, it extended its gaze over the normal person to establish early
detection, to advise on appropriate behaviour and relationships and to
enable the potentially abnormal to be adequately known.
The domain of panopticism was 'that region of irregular bodies, with
their details, their multiple movements, their heterogeneous forces, their
spatial relations'; it required 'mechanisms that analyse distributions, gaps,
series, combinations, and which use instruments that render visible,
record, differentiate and compare: a physics of a relational and multiple
power, which has its maximum intensity not in the person of the king, but in
the bodies that can be individualised by their relations'.6 The Dispensary
further refined this gaze, these techniques of analysis, to fix them, not on
individual bodies so much as the interstices of society; the Dispensary was a
mechanism of power which imposed on the spatial arrangement of bodies
io Political anatomy of the body
the social configuration of their relationships. The Dispensary was a device,

above all else, for making visible to constant surveillance the interaction
between people, normal and abnormal, and thereby transforming the
physical space between bodies into a social space traversed by power. At
the beginning of the twentieth century the 'social' was born as an
autonomous realm. 7
Social hygiene
Power assumes a relationship based on some knowledge which creates and
sustains it; conversely, power establishes a particular regime of truth in
which certain knowledges become admissible or possible. The configura-
tion of power to be found in the Dispensary was both a product of
knowledge and the basis for a cognitive transformation of certain aspects of
medicine in the early twentieth century.
Health was no longer to be regarded as a private and immutable state of a
body, 'an inborn secret between the individual and his doctor', as Williams
argued, but as something social and relative, 'an objective to which the
individual could strive'. 8 The old regime treated the body as an object and
attempted to control its relationship to the natural environment by
identifying particular aetiological factors and promulgating sanitary laws
of health which governed its activities. Hope's Textbook ofpublic health, of
1915, perhaps typified the focus of attention by dealing with the dangers of
site, soil, water, air and food. 9 With the advent of the social, the old 'public'
health all but disappeared. As Hill pointed out in 1916: 'The old public
health was concerned with the environment; the new is concerned with the
individual'. 10 Within several decades new concerns intruded into the texts
of public health. Burn's Recent advances in public health, of 1947, for example,
contained a large section on 'public health and the individual' in which
there was separate discussion of mother and child, nursery care, the school
health service, health education, mental health services, dental health,
medico-social services, the handicapped child, care of the family and
welfare of the aged. 11
Under the old system the natural environment was the potential source
of ill-health. Under the new hygiene the natural environment was not of
itself dangerous, but merely acted as a reservoir. The danger now arose
from people and their points of contact. It was people who carried ill-health
from the natural world into the social body and transmitted it within. The
epidemiological gaze therefore began to shift from the environment to the
mode of transmission between people and to ramifications of social
relationships: 'Modern writers fail to find any useful or basic significance in
contagions as contrasted with infections.' 12 The new hygiene, as proposed
by Newman, depended on an educated people 'willing and able to practice

the way of health'. 13 Preventive medicine was therefore no longer restricted
to environmental questions and sanitation 14 but became concerned with
the minutiae of social life. Might not health, Newman argued, be promoted
'by maintaining a clean mouth and clear breathing, and by abstinence from
spitting, sneezing, coughing and shouting at each other?' 15
The clinical gaze within the hospital had outlined and sustained the
passive and discrete body by localising illnesses within it. In similar fashion
the Dispensary gaze established the reality of the social by identifying
diseases of social spaces, of contacts and relationships. Thus, as the social
basis of the disease justified the Dispensary as the appropriate mechanism
to combat it, so too the Dispensary established, by its deployment in the
community, the social origins and character of the new health dangers.
Tuberculosis, which had, until the closing decades of the nineteenth
century, been primarily a disease of individual bodies and of environmental
neglect, became a disease of contact and social space. The techniques for
monitoring the social can be seen in the increasing number of tuberculosis
dispensaries established in the early decades of the twentieth century. They
can be identified in the 'pilgrimage exhibitions' of the National Tubercu-
losis Association (founded 1898) to spread the dangers of casual social
contact, which, by 1914, had distributed some 80000 leaflets and books
extolling the virtues of alertness to this disease of human mixings. 16 How
better to keep the problem under constant surveillance than by pressing,
from 1913 onwards, for the disease to be compulsorily notifiable? And from
1936, following the legal requirement for confidential registers of notified
persons in 1930, to keep all contacts under observation for four years? 17
Together, these various measures outlined a mechanism for social
surveillance and for raising consciousness in the community thus observed.
This greater consciousness, on the one hand enabled the intrusion of
surveillance to be more easily justified, and, on the other hand made the
potential patient a part of the surveillance mechanism. 'Intelligent
individuals, realising their duty to their life partners and society at large'
were therefore expected to consult their doctor on the social implications of
their disease - Should they get married? Should they have children? Should
they see their spouse?18 Tuberculosis became a disease of human contact
which, when adequately monitored, potentially revealed the social fabric of
a community to an observing gaze.
The gaze of the Dispensary identified and constructed a social and
sanitised area between individuals by the single device of using the
knowledge that tuberculosis could be transmitted through 'respiratory
contact'. The space between mouths and between noses became subjected
to medical surveillance and the relationships, both familial and casual,
which brought people into contact, became an item of medical record. It

was the movement of the tuberculosis bacillus, invisible yet deadly, which
outlined the social space between individuals.
For the purposes of a medical gaze, intent on focusing on the relationship
between individuals, any disease such as tuberculosis which could be
directly transmitted between people served to map social space. Thus the
national outcry against the spread of venereal diseases early in the century
was not only a manifestation of moral outrage but also of latent surveillance
possibilities: the path of venereal diseases throughout the community
traced the threads which linked one person intimately with another. The
dangers of venereal disease could be used as a means of observing
behaviour, educating thoughts and teaching contacts.
The Royal Commission, established in 1913 to investigate the whole
problem of venereal disease, recommended a national system of'clinics' to
provide free diagnosis and an early campaign to educate the public. 19 The
propaganda campaign was organised by the National Council for Combat-
ing Venereal Diseases, but it took the form of warnings against the dangers
of illicit sexual encounters and a deliberate policy of avoiding advice on
appropriate prophylactic measures subsequent to such an encounter, even
though 'prophylactic packets' against venereal disease were available and
had been used successfully in the army. These were not thought appropri-
ate for civilians, however, as they could provide an incentive to immorality
through removal of the fear of venereal disease. They would also, it was
held, outrage public feeling and constitute a blow to a national crusade for
higher standards of conduct. 20
Yet the promulgation of these tactics of repression had a negative effect
on the efficiency of the Dispensary. Free clinics were provided by local
authorities but they remained stigmatised; compulsory notification was
proposed but at the same time felt to be impractical in that it might drive
the disease underground; and the tracing of contacts in the community
could not proceed while fear governed the manifestations of the disease.
This 'conspiracy of silence' which extended to even a mention of the
diseases (did not syphilis and gonorrhoea 'sound evilly to the ear' 21 )
prevented the Dispensary laying its observing networks on the threatened
community and opening the secret and intimate movement of sexual
contact to the meticulous hygiene of the medical gaze.
By the 19205 there was a noticeable shift in the emphasis of venereal
disease propaganda. The moral connotations were less overtly stressed and
the positive effects of combating the disease emerged. The emphasis of the
work of the National Council was changed from fear to 'constructive'
propaganda and a new name, The British Social Hygiene Council, was
taken in 1925. 22 In 1930 the annual conference of the Council proposed
increased provision for the treatment of venereal diseases and reported
good follow-up of cases in Swansea. 23 Imperial social hygiene congresses
were arranged to bring to the nation's attention the economic importance of
combating venereal disease in the colonies: 'virility and efficiency of native
races is of prime importance to the development of Empire'. 24 Through the
techniques of social hygiene, venereal disease became a device for
integrating a notion of illness - far removed from the closed world of the
discrete body - with a system of civil administration, for there was now 'a
general acceptance in every outpost of Empire that health and government
were linked'. 25
Venereal disease changed from being used as a means of forbidding
certain relationships to a mechanism for observing them. The underlying
social relationships themselves were brought into open discourse. The
British Social Hygiene Council, instead of simply condemning illicit
non-marital relationships, began to emphasise the need to 'promote social
progress and preserve and strengthen the family'. 26 It produced a booklet
on marriage, in 193a,27 held a summer school of 'problems relating to
family stability and preparation for marriage', in IQ3428 and produced a
Year Book, in 1935, covering 'marine welfare, housing, maternity and child
welfare, illegitimacy, juvenile delinquency, probation, deafness, and
tuberculosis'. 29 The form of the Dispensary thereby fixed itself on the field
of venereology and began to create a network of surveillance that monitored
the social contacts, values and environment of recorded patients.
The child as object and problem

The technology of social hygiene which had, through the new contact
diseases, established the identity of that invisible and problematic space
between bodies, also manifested itself in the invention of the child as an
object of the medical gaze. The body of the child was, of course, not only
fabricated by the medical discourse that began to fix on it towards the end of
the nineteenth century, but also by the various moral and educational
concerns which contemporaneously enveloped it. At the same time as the
body of every child was subjected to educational surveillance through the
introduction of compulsory education the child entered medical discourse
as a discrete object with attendant pathologies. Goodhart published the
first edition of his The diseases of children, in i885;30 Hutchinson, his Lectures
on diseases of children, in igo4;31 and Garrod, his Diseases of children, in
1913. 32 A Society for the Study of Diseases in Children was founded in
1900 and in 1908 it became a founding Section of the Royal Society of
Medicine. 33
The figure of the child became caught up in a panoptic vision. Childhood
was a state in which the child could be manipulated and transformed within
the new field of observation established by the large halls of the new schools
and the open wards of the new childrens' hospitals. As Cameron noted in
his classic text, The nervous child, first published in 1919, 'the body of the
child is moulded and shaped by the environment in which he grows. Pure
air, a rational diet and free movement give strength and symmetry to every
part.' 34
However, while the figure of the child became caught up in a panoptic
vision at the beginning of the twentieth century, it was also apparent that
the child could not be adequately observed in isolation. The hospital, the
clinic, the school were all admirable places from which to exercise
surveillance over the child, yet they were not points from which the child
could be observed in its 'natural' environment, namely, the home. Thus
two related strategies can be identified as being developed around the child
at the beginning of the century. First, there was the panoptic gaze which
sought in the schools and hospitals to examine and inspect the actual body
of the child; second, there was the Dispensary which attempted to map and
survey the social relationships of the child in the community proper. It was
Cameron's view that childhood should become part of the remit of
preventive medicine: 'more and more a considerable part of the profession
must busy itself in nurseries and schools, seeking to apply there the
teachings of Psychology, Physiology, Heredity and Hygiene'.35
As these surveillance mechanisms increased in generality and intensity
in the twentieth century, so too the apparent dangers from inadequately
supervised children increased. Nervous children, delicate children, neuro-
pathic children, maladjusted children, difficult children, over-sensitive
children and unstable children were all essentially inventions of a new way
of seeing childhood. 'A tendency to quarrel, to make violent friendships, to
engender bitter dislikes, to attend unduly to bodily functions, to night
terrors, to unreasonable fears, grief, introspection and self-examination and
to separation from family and friends', marked out these potentially
dangerous currents, dangerous because some of these children might
'eventually rise to a high career in public affairs'. 36
Milk depots were opened in various towns in the early years of the
twentieth century to provide milk (bottled under hygienic conditions) to
mothers with small babies. Attendance at a milk depot meant that the
children were closely scrutinised: they were weighed once a week, their
homes were visited by health visitors who reported their progress to the
Medical Officer of Health and the mothers were provided with cards on
which to record the weight of their child. While on the one hand the milk
depots praised the value of breast milk, in their practice they encouraged
attendance to obtain cow's milk so that the child could come under
observation. In effect, the milk depot functioned as a surveillance

apparatus, integrating in a hierarchy of observation the Medical Officer of
Health, health visitor and mother and compiling for the body of each young
child an individual dossier. 37
But what of the mothers who declined to bring their children to the milk
depots? How could the gaze extend itself to this child who was unknown to
the medical services? This problem had been tackled in Huddersfield in
1905 by paying the mother one shilling for notifying the birth within 24
hours to the MOH. This scheme of birth notification was made compulsory
in 1906 for Huddersfield, and in 1907 a National Birth Notification Act was
passed, in 1915 becoming compulsory. With notification of births, visits
from assistant MOsH, constant observation by the health visitor and the
requirement, from 1910, that only qualified midwives and doctors could
supervise the actual birth, the child, from its very moment of entry into the
world, became an object of medical interest, for the first time a visible body
with its own individual record.
A national campaign against infant mortality was established on the
basis, as McCleary has observed, that deaths in the first year of life were not
a problem of sanitation so much as of personal hygiene. 38 Maternity benefit
was introduced - available to those mothers who registered the impending
birth and ante-natal clinics were founded. Baby clinics, day nurseries and
nursery schools were opened, each establishing a point from which to
observe the behaviour and relationships of the young child.
Medical surveillance of the older child was entrusted to the school
medical service which was established in 1908 following the report of the
1904 Interdepartmental Committee on Physical Deterioration. 39 The
service was provided through two clinics, one for treatment and one for
inspection. The treatment clinic operated as a panoptic structure: a point at
which bodies were individually examined, abnormalities diagnosed and
appropriate treatment provided. The inspection clinic, on the other hand,
followed the structure of the Dispensary. It screened all school children at
varying times for incipient and manifest disease; it organised visits to
childrens' homes by the school nurse to report on conditions, monitor
progress and advise mothers on the care and treatment of their children.
And it functioned as a co-ordination centre: records of children were
maintained, reports from the community were filed, observations were
up-dated. 'From it [the inspection clinic] should be directed and organised
the work of the School Medical Officer, school nurse, attendance officer and
Care Committee.' 4"
It was at the beginning of the twentieth century, therefore, that a link was
forged between systems of educational and medical surveillance. On the
one hand, the educational system provided a mechanism for one compo-
ncnt of the Dispensary: the inculcation of social hygiene. Hygiene was 'an
integral part of the ordinary school routine ... a practice rather than a
theory, a way of life rather than an abstract idea'. 41 On the other hand, the
medical system provided a mechanism to monitor educational progress.
Inspection clinics became assessment as well as diagnostic centres, in part
to offer, within a medical discourse, reasons for educational failure. With
the later growth of child guidance and the localisation of the vagaries of
mental development to the innocence of childhood, a parallel school
psychological service emerged to focus on the latent mind of the child.
Social space and social time

The Dispensary offered a reconstruction of social space and of social time.
Where panopticism had, in effect, offered to the observing eye that which
was in an enclosed space, the school, the hospital or the prison, the
Dispensary, through its juxtaposition of observation and community,
replaced enclosed physical space with an open and social domain.
A focus on space in buildings and between bodies was not new to the
medical world of the twentieth century. The sanatorium for tuberculosis,
with its emphasis on open air, had originated in 1840 when Bodington
recommended 'a pure atmosphere, freely demonstrated without fear'. 42
The growth of sanatoria, however, was slow, especially in England, until
the closing decade of the nineteenth century and it was not until the early
twentieth century that the space surrounding and between bodies came
into sharper medical focus. Nineteenth-century miasmatic theory, which
had stressed the dangers of impure air, was - in a new form - revived in the
claim that pure air was beneficial to health.
The once dark and enclosed school was opened up: large windows which
could be opened during lessons to allow the passage of air were recom-
mended. School hygiene was discussed in public health textbooks in terms
of a school design which would allow free space to circulate around the
child. 43 The first open-air school was opened in 1907 by the London County
Council and by 1931 there were 80 such schools catering for 9000
children.44 Even in schools with traditional architecture it was recom-
mended that classes be held outside, in the yard or in the park. The Lancet,
in supporting this policy, suggested that on cold days exercises could be
given at regular intervals to keep the children warm. 4-"1
The outdoor conditions were intimately bound up with the new
conception of health. They were not intended for the fittest students but, on
the contrary, for the relatively unfit. Spartan conditions had been a system
for strengthening already strong bodies but in the Dispensary they were
deployed around the weakest. Open-air schools were recommended for
'debilitated, undernourished children, those with incipient pulmonary

tuberculosis and children who were nervous and excitable'. It became
official policy to admit more and more nervous and maladjusted children to
these open schools. 46
Industrial efficiency was studied in the context of air, temperature,
humidity, movement. Air conditioning and ventilation were discussed
jointly, by hygicnists and clinicians. 47 The old idea of closed wards and
mechanical ventilation to prevent the transmission of microbes was
reversed and 'natural cross ventilation' recommended.48 Though at first
only used on the tuberculous patient, such ideas became equally applicable
to medical, surgical and infectious-disease wards and in convalescent
homes. Hygienic space itself became therapeutic, open windows (together
with warmer clothing) could promote health. 49
The construction and management of space within hospitals was no
longer simply governed by panoptic principles through which all detail
might be visible - but by notions of a hygienic and social matrix in which
bodies mixed. 'Have we yet designed the ideal ward block? What arc the
proper amounts of wall space and floor space for patients of different
types?' 50 Even in the siting of such hospitals it was advised to use the
'health-giving' factors of a site to their maximum advantage. 51
The new hygiene opened up the space around bodiesjust as purposefully
as it had opened up the space around the hospital or clinic. The Dispensary
offered a perceptual structure which operated in an open yet essentially
social space. It offered an analysis of bodies in space a space through
which bodies met and interaction took place. The old system of quarantine
excluded, the new system allowed a controlled passage. 'Quarantine is the
source of all our preventive method against the spread of infectious disease
.. . The dominating principle of modern as opposed to the old quarantine is
that it must be a sieve not a dam.' 52
The conceptualisation of space in which the Dispensary operated - in the
community and around bodies - could also be found in the cognitive
spatialisation of the new diseases. Panopticism had been a reductionist
gaze, sub-dividing space in the hospital and in the body. Pathology was
localised and static. The Dispensary, on the other hand, revived an older
tradition from the eighteenth century, before tissue pathology came to
dominate clinical medicine, when disease existed within the body but
manifested itself without regularity at one point, then later at another.
Symptoms appeared, disappeared, reappeared. The symptoms in this old
regime could no more be used to localise a pathology than could actual
physical examination of the body. Symptoms constituted a somewhat
random manifestation of the illness through bodily space and time and the
physician's task was simply to wait, to observe and to listen. 53
Similarly, the Dispensary did not localise pathology. A single patient

with venereal disease was simply a manifestation of a disease which in all
probability had already moved on and was manifesting itself elsewhere.
Venereal disease might disappear from a patient but re-emerge in a casual
acquaintance, then later reappear in the original patient. Disease was
constituted in the social body and it was the social movement of the disease,
as it traversed that body, which had to be observed, monitored and
interpreted, thereby establishing by its analysis the very existence of that
same social space. Whereas the clinical gaze that was established at the end
of the eighteenth century made, for the first time, the space of disease
coterminous with the space of the body, 54 the extended gaze of the twentieth
century discovered in the new diseases a pathological form which was
superimposed on the outline of the social body.
Where the Panopticon was a device for monitoring and constituting
bodies, the Dispensary was a mechanism for surveying, and thereby
rendering problematic, particular relationships between those same
bodies. In its institutional arrangements - the tuberculosis dispensary, the
venereal disease clinic, the school medical service inspection clinic or the
child welfare clinic - the Dispensary cast an observing eye over the
community. Counting, assessing, tracing, following, recording, coordinat-
ing, the Dispensary constructed the outlines of a social map in which
particular social relationships came into increasing focus through their
constant and meticulous scrutiny. At the same time both justification and
explanation were provided for this surveillance by the 'invention' of new
medical problems - venereal diseases, tuberculosis, the nervous child,
infant mortality, the feckless mother - which, if left unsupervised, might
have threatened the very fabric of society, but which, when adequately
monitored, could serve instead to throw into relief the essential social bonds
that linked one person with another.
In 1912 the Section of Epidemiology of the Royal Society of Medicine
(one of its founder sections) extended its purposes: to observe the persistence,
as well as the variability, of disease in the community. 55 The new medicine
had to address itself to time, to the movement of pathology rather than its
localisation.
Invention of the neuroses
In 1906 Bruce published his Studies ofclinical psychiatry-a standard textbook

of psychiatry which dealt exclusively with the classification, aetiology,
diagnosis and treatment of insanity. 1 In 1944, the sixth edition of
Henderson and Gillespie's A textbook ofpsychiatry-was offering considerable
space to the 'psychoneuroses' and, moreover, had decided to place them
before discussion of the 'psychoses' (the new term for insanity) 'because
they are much more common'. 2 How was it that within the space of less
than 40 years the object of psychiatric interest had changed so much?
How had the psychoneuroses emerged into such prominence? And
how had insanity (or madness) suffered a change and relative decline in
importance?
Insanity and neurasthenia

The problem of madness had first come into prominence some two
centuries earlier, in the Age of Reason. Foucault has argued that the
moment of its discovery, when Pinel struck off the chains of the madmen in
Bicetre, did not, however, signify a new liberation as much as the full
institutionalisation and confinement of madness. 3 With its new classi-
fication, madness was separated from debauchery, criminality, idleness,
vagabondage and vagrancy (to all of which it had seemed as one) and
confined to the asylum: 'The obscure guilt that once linked transgression
and unreason is thus shifted; the madman, as a human being originally
endowed with reason, is no longer guilty of being mad.' 4 As a result,
madness became imprisoned in a 'moral world' which successfully
delineated the world of reason from unreason. 5 Confinement protected the
pure community and sanity was reaffirmed by the exile of the insane. 6
Towards the end of the nineteenth century a new problem of mental
functioning began to emerge. It was observed that some people suffered
from 'mental instability' which did not of itself constitute madness; medical
attention started to focus, not on unreason, but on the vagaries of
apparently ordinary mental functioning. Undoubtedly, other diagnostic
IQ
categories - cholorosis, anaemia, even malingering - had been used

previously to classify problems of mental instability;7 but in these
diagnoses, nervous irritability had represented only one (and perhaps a
minor) manifestation of the condition. Mental instability began to be
defined as a problem in its own right only towards the end of the nine-
teenth century when the neuroses were constituted as objects of medical
discourse. 8
One of the earliest manifestations of the new problem of mental
instability can be found in the diagnoses of'nerves' and 'neurasthenia'. In
the first two decades of the twentieth century, neurasthenia took its place in
medical textbooks, together with hysteria and psychasthenia, as the most
important of the so-called neuroses. Neurasthenia was variously described
but it seemed to be mainly characterised by nerve 'exhaustion' or fatigue. 9
It was believed to be brought about by over-exertion, and treatment was
mainly by rest and routine.
Psychiatry, the specialty of the insane, incorporated these manifestations
of mental instability into its theories of madness by describing them as
precursors of insanity. The neuroses were simply symptoms or early
warnings of impending madness. In his textbook Psychological medicine, of
1905, Craig sub-divided his chapter on general neuroses into three
sections: epilepsy and insanity, hysteria and insanity, and traumatic
neuroses. 10 Cole, too, in his Mental diseases, published in 1913, classified
the neuroses under the heading 'neuroses and insanity' - a classi-
fication which continued up to the third edition of the book published in
1924."
The brevity of the discussion of the neuroses and their treatment as
precursors of insanity, to be found in these psychiatric texts, can partly be
explained by the fact that psychiatrists claimed rarely to see the condition.
As Craig & Beaton pointed out in 1926, 'until quite recently the
neurologists never saw the case of insanity shut up in the mental hospitals
and the mental hospital physician, the alienists or psychiatrists never saw
the case of "nerves" ' 12 It was therefore left to the neurologist, the general
physician and the general practitioner to cope with these 'new' complaints.
In consequence, neurasthenia appeared contemporaneously in the neuro-
logical textbooks as primarily a neurological problem. Although it might
manifest itself as an affliction of the mind, as 'nerves', fatigue or 'brain fag',
its basis, it was claimed, was decidedly neurological. 13 And as disease was
'inconceivable without some underlying physical basis' 14 , functional
disorders such as neurasthenia, in which there was apparently tissue
'dysfunction' [sic] without structural abnormality, were seen to be rooted in
real if unrecognised physical processes. 15
Invention of the neuroses 21
Medicalisalion of the mind

The uneasy relationship between the old disease of madness and the new
problem of the neuroses in psychiatry was transformed in the second
decade of the new century. The change is shown, somewhat dramatically,
in the third edition of Stoddart's textbook, Mind and its disorders. 16 The
previous editions had devoted the customary chapter to neurasthenia - an
illness characterised by mental fatigue - which might be bestowed on their
progeny by parents who had used up their stock of nervous energy. The
third edition of 1919, however, reported that 'since the last edition I have
fundamentally changed my attitude towards mental disease'. 17 Stoddart
confessed to having been influenced by the new Freudian ideas: he now
included a chapter on psychoanalysis, introduced the notion of anxiety
neurosis and, following Freud, suggested that neurasthenia was a product
of auto-eroticism and masturbation.
Many of Stoddart's psychiatric colleagues, however, were less enthusias-
tic about the new ideas. The second edition of Cole's textbook, published in
the same year, found 'food for reflection' in the psychoneuroscs 18 but only
added anxiety neurosis as a diagnostic category in the third edition of 1924.
Norman's textbook of 1928, Mental disorders for students and practitioners,
continued to link all mental disorders to insanity and gave only one mention
of the Freudian school, while remarking: 'there seems some difference of
opinion in this respect'. 19 Devine's book of 1929, on Recent advances in
psychiatry, dealt exclusively with the psychoses (the new term for the
insane). 20 Cannon & Hayes in their textbook of 1932, The principles and
practice of psychiatry, acknowledged anxiety and neuroses as psychogenic
problems but only in as much as they might contribute towards insanity. 21
If Stoddart was an exception to the general trend it is perhaps worth
noting that in 1919 he was no longer a mental hospital superintendent;
when he was 'converted' to Freudian psychopathology he was a lecturer in
mental diseases at St Thomas's Hospital Medical School. In moving from
the world of the asylum to the general hospital he reflected the difference in
attitudes towards mental disease in these two domains. During the 19203
and 19303 the main thrust for the incorporation of problems of mental
instability (and of Freudian ideas) into medicine came, not from a
psychiatry rooted in the asylum, but from a general medicine faced with a
generalised problem of mental functioning.
While psychiatric textbooks tended to ignore the new developments
these latter were rapidly taken up by neurologists22 and found their way
into the neurological texts. Stewart, the author of The diagnosis of nervous
disease, had completely rewritten the chapter on psychoneuroscs in the sixth
edition of 1924. While he still felt that these mental diseases manifested
themselves through 'molecular changes' the new terminology of conscious,
unconscious, complexes, etc., was explained. 23 Similarly, Thompson's
Diseases of the nervous system, of 1915 (second edition), accepted that
neurasthenia merged into anxiety neurosis and by 1921 (third edition) used
the familiar Freudian language in which to describe mental pathology. 24
The appearance of the psychoneuroses in medical texts formalised an
increasing concern of general medicine with the mind. The mind in all its
detail had become important not the diseased mind of the mad or insane,
but the ordinary mind of everyone. As Sir Humphrey Rolleston, Regius
Professor of Physic at Cambridge and President of the Royal College of
Physicians, claimed in 1925: 'probably the bulk of patients in ordinary
practice present some disorder, however slight, of mind, conduct or
feeling'.25
The diagnosis of insanity had been a ritual of exclusion; the madman, like
the leper, was caught up in a regime of rejection and exile. Within the
confinement of the asylum, it is true, there had been a panoptic gaze which
sought to observe, analyse and partition the amorphous mass of the insane,
but these techniques were only secondary to the great binary division of
madness from sanity which informed the psychiatric method. Madness
represented the political dream of a pure community by marking the mad.
In contrast, the neuroses celebrated the ideal of a disciplined society in
which all were analysed and distributed.
Neurasthenia had enabled the identification of the fatigued and
exhausted; the neuroses recognised stress and its effects. At first, while
neurasthenia still survived, it was the stress of masturbation; later it
became more generalised - a medical eye on stresses of childhood,
parenting, workshops, schools and homes. Those forces, ever present in
social space, which impinged on the functioning of individual bodies, were
theoretically refined into a discourse on stress and coping. A general
medicine which, since the beginning of the nineteenth century, had offered
surveillance and examination of the deviant body, extended its 'gaze' to the
mind of everyone.
The deployment of this new medical gaze to the mind of everyone
involved various tactics. First its limitless range was affirmed. Neuras-
thenia, which tended to be inherited by the few, gradually disappeared to
be replaced by the neuroses, which might appear in anyone. Neurasthenia
was reputedly in decline during the i92OS26 .and it was left to Buzzard, the
king's physician and Regius Professor of Medicine at Oxford, to declare it
merely a 'dumping.ground' for inadequately recognised cases of anxiety
neurosis and depression. 27
Second, the deployment of a medical gaze over the mind inevitably
brought conflict with those bodies and institutions which had traditionally
kept a guard over certain specific aspects of mental functioning. In an
address in 1927, entitled 'Medicine and the church', Buzzard warned the
clergy against interfering in the treatment of the mind. It was, he claimed,
the 'one bone of contention' between church and medicine. 'I have taken
the courage of my profession in my two hands today and have declared that
we make no claim to spiritual healing.... Any fears I may entertain are for
the Church, who if she listens to some of her disciples, might find herself in
competition, not with medicine, but with quacks and charlatans.' 28
The other group whose unorganised activities threatened the unified
medical gaze were lay people who practised psychotherapy. Ross claimed
in his Morison Lectures of 1935 that there were grave dangers in allowing
unqualified lay people to treat mental disorders. 29 These dangers, the Lancet
suggested, lay in the fact that physical and mental illness could not be
sharply separated so the psychotherapist must of necessity have a basic
training in the rest of medicine. 30
Third, if the new medical gaze to the mind was to be effective then it
would have to be adequately taught. In its annual review of medical
education, in 1920, the British Medical Journal made its usual perfunctory
mention of psychological medicine: 'The study of mental disorders has long
been a necessary part of the ordinary medical curriculum.' 31 In 1921 it
added the qualification that it had also been 'somewhat neglected'. 32 In
1922, it had both been neglected and 'its importance scarcely recog-
nised. . .. Of late it has become apparent that mental disorder constitutes a
social and medical problem of great significance, and there is little doubt
that in future it will be recognised as one of the most important specialities.'
This newly important aspect of medicine was no longer constrained to the
severe forms in the asylum but included 'mild and often unrecognised
psychoses and various types of psychoneuroses'. 33
Bernard Hart, in 1918, had first proposed that psychology be taught in
the medical curriculum and George Newman, the Chief Medical Officer,
had also commended it in a memorandum to the Ministry of Health in
ig23. 34 The British Association was sufficiently concerned to appoint a
committee to consider the place of 'normal psychology' in the medical
curriculum. It reported in 1928 that in half the country's medical schools
there was no instruction in this area. 35 The Lancet thought this 'absurdly
inadequate' given that psychological medicine was no longer confined to
the asylum but embraced 'a far wider field'. 36 The British Medical Journal
agreed that normal (and abnormal) psychology was a necessary part of any
medical curriculum: 'it is now universally admitted that a large part of
every doctor's practice consists of minor conditions of a "functional"
nature 37
Debates ensued about the type of psychology which should be taught and
about whether it should be taught by psychiatrists, physicians or
surgeons;38 but, as the Lancet pointed out, the issue of whether more
instruction was desirable was not in dispute.39 Psychology had become an
indispensable part of medicine and this position would have to be reflected
in the curriculum.
Fourth, the new medical gaze to the mind of everyone was also an
examination of the mind of the individual. Yet that individual was not a
'given' but had itself been fabricated as a physical object within the older
medical gaze of the panoptic vision. The new regime therefore called for an
integrated gaze, a synthesis of the physical and the psychological, so that
the individual, both organically and mentally, could be subjected to a single
analysis.
On the one hand, this unitary gaze could be effected by treating the
physical and the psychological as two sides of the same coin. The Royal
Commission on Lunacy and Mental Disorder, which reported in 1926,
argued: 'There is no clear line of demarcation between mental and physical
illness ... a mental illness may have physical concomitants ... a physical
illness may have, and probably always has, mental concomitants.'40 On the
other hand, there were various attempts in the inter-war years to construct
a 'unified theory' of mind-body relations. Pavlov's experiments in con-
ditioned reflexes, reported in his 1928 Croonian Lecture, was research, the
Lancet felt, which belonged to the borderland of physiology and
psychology;41 Meyer proposed the notion of reaction-types to explain
biological reactivity to psychological stimuli;42 Adler argued that mental
tension manifested itself in defective organs and endocrine inbalance.43
The belief in the 'indissoluble unity of mind and body' was the basis for
membership of the Medical Society of Individual Psychology, founded in
1931. Its chairman, Langdon-Brown, the Regius Professor at Cambridge,
confessed that 'sheer force of experience' had led him 'to realise the need for
a more psychological approach to medicine ... as many people were ill
because they were unhappy, as were unhappy because they were ill' 44 He,
personally, felt that the sympathetic nervous system - especially the
pituitary - was of misunderstood importance in the genesis of mental
disorder.45 Other members of the Society suggested that there were
problems of 'fine adjustment of organic senses in psychoneurotics, in
particular poor sight and wax in the ears', or there was a problem of'tight
collars and tight shoes', or that 'hyperthyroidism, septic tonsils, constipa-
tion and oxalicia' were to blame. Little sympathy was offered to the
one-sided theories, derived from Freud and Jung, which were imbued with
'a great deal of washy and spineless eclecticism that degenerates into
clinical opportunism, if not humbug'.46
The Tavistock Clinic, together with its associated Institute of Medical

Psychology, also promoted a unified psychosomatic approach to diagnosis
and treatment, and for most of the inter-wars years had to keep its waiting
list closed, such was the demand for treatment.47 Crichton-Miller, the
Clinic's founder, published his views on aetiology in 1920 in his book,
Functional nerve disease. There he argued that the emotions, sepsis, the
endocrines and blood circulation, all had interdependent effects on mental
stability.48 '
His approach was undoubtedly supported by the Medical Advisory
Board of the Clinic, which included the physicians Buzzard and Langdon-
Brown and the 'philosopher-surgeon', Trotter. Despite the Clinic's later
reputation for promoting psychodynamic techniques, a detailed physical
examination was carried out in almost every case for specific organic lesions
such as focal sepsis or thyroid disfunction.49
This approach was maintained by Crichton-Miller's successor, Rees,
who, in a textbook on psychological medicine, published in 1936, continued
to argue that anxiety symptoms were caused by sympathetic and para-
sympathetic nerve function. Surely, he argued, 'there must be a direct
connection between physiology of the nervous system and psychology' such
that there is a 'vicious circle of mental and physical inter-action'.50 Had not
the Freudian dream once been the rooting of mental functioning in cerebral
physiology?
It would be misleading, however, to suggest that there was a broad
consensus on theories of mental disorder; there was certainly a struggle
between, for example, the exclusively psychogenic British Psychoanalytic
Society and the notion of psychosomatic unity so strong in general
medicine. Yet it would be equally inappropriate to characterise the debate
simply as one between psychodynamic and organic theories. The struggle
lay, not between theories, but within the myriad interactions that occurred
daily between a gaze and its object, a disciplined mind.
The mind was represented to the gaze in words. Whereas under the old
regime the body of the patient had to be made legible to the physician's
interrogation, under the new regime the body produced its own truth which
required, not legibility, but encouragement. The patient had to speak, to
confess, to reveal; illness was transformed from what was visible to what
was heard. The social space between doctor and patient became, not an
impediment to the legibility of the passive body, but the complex matrix in
which words were captured and the mind crystallised.
It would be wrong to say the mind was discovered, as that presumes it
had an existence prior to the gaze; but neither could it be said to have
independent existence after its fabrication other than in the discourse,
strategies and interaction that gave it meaning. As in the analysis of the
social, it is necessary to be nominalist. The social was created by a gaze

which relentlessly mapped and monitored the physical space between
bodies and it is in this same space that the mind was constituted. In the
nineteenth century the mind had been a faculty of rationality coterminous
with the cerebral tissues; in the twentieth century the mind was established
in a social space of relationships and interaction which, according to
contemporary theories, were both of causal significance, and particular
manifestations by which it might be observed. This is not to imply that
these contemporary theories were anything but links, in terms of the new
regime of truth, between the various elements of mental disorder which
emerged at the beginning of the century. Equally, the institutional settings,
professional structures and organisational settings which developed
around the mind, were both phenomena that sustained the existence of the
mind and, at the same time, products of the monitored space between
bodies in which the mind and the social were born.
The mind, as it was observed in the inter-war years, was therefore a
fabrication of the disciplinary mechanisms of the Dispensary. The medical
gaze shifted from body to mind: a focus on relationships and on interaction;
a conceptualisation of pathology as existing in the social body, constantly
appearing, disappearing, reappearing; a need to know of its various
manifestations and the development of techniques for its observation; a
gaze turned on the 'normal' population, as much as on the diseased, in an
attempt to identify the incipient signs of instability; a medicine focused, not
on the mind of the mad, but on the mind of the precariously sane. Insanity
and neurasthenia had been afflictions of those constitutionally pre-
disposed; neurosis was a potential problem for everyone. As Ross argued in
his book on The common neuroses, in 1923, the difficulties experienced by the
neurotic were greater by far for him than they were for normal people 'but
they are the same difficulties which all of us have' 51
A perpetual gaze
Rolleston, in arguing that the bulk of patients in ordinary practice had
disorder of mind, conduct or feeling, also charged that 'the earlier
departures from the normal should be communicated to the doctor and
remedial measures started without delay'. 52 A medicine which gazed into
the smallest interstices of human lives could maintain an orderly society. A
constant surveillance over mental functioning could keep at bay the
manifestations of stress which threatened the precarious strands that made
up the social order.
The observation and surveillance of the mind started with the child. The
advantage of dealing with the child was the potential for change:
'[children's] abnormalities are as unshaped as their normalities and they

can often be modelled to what shape we please'. 53 The child was father of
the man. Moreover, 'children are not born with a highly developed faculty
of control or sense of responsibility. They have to acquire our standards of
right and wrong carefully, and in many cases with difficulty.' By the age of
twelve or fourteen the correct instincts were normally present 'but in a
certain number of people a tendency to dishonesty and untruthfulness
persists into young adult life, and may die only with the person'. 54
A strategy was therefore devised to guard against such unwanted
outcomes. The GP could observe the child and advise on correct
parenting. 55 Schools could monitor the progress of the child, not simply by
examinations, but by such new techniques of surveillance as serial
psychometric testing and through the new discipline of educational
psychology. 56 The mental welfare of children could be secured by a new
medicine of children57 (British Paediatric Association, founded 1928),
new clinics (Children's Clinic for the Treatment and Study of Nervous
and Delicate Children, founded 1928), new research establishments58
(National Institute of Child Psychology, founded 1931) and the notion of
child guidance to correct, at an early stage, the potential instability of adult
life (Child Guidance Council, founded 1927). 59
The problems in the mental life which was provided for the child
manifested themselves as new diagnostic groups. Cameron identified the
nervous child as a product of parental neglect of proper mental develop-
ment, in 1911 ; 60 the Sections of Psychiatry and of Diseases in Children at
the Royal Society of Medicine jointly discussed the 'difficult child', in
ig2961 , and the 'eneuretic child', in ig3462 ; in his chapter in Diseases of
children Guthrie focused on the 'neurotic child';63 the Chief Medical Officer
at the Board of Education recognised the 'neuropathic child', in 1920, the
'maladjusted child', in 1927, and the 'unstable child', in ig28;64 special
educational provision was made for the 'delicate child' and the 'nervous
child'; 65 medical concern was expressed for the 'over-sensitive child' and for
the 'solitary child'. 66 The child was construed as precariously normal, as
liable to slip into inappropriate or problem behaviour without constant
vigilance. The solitary child, for example, suffered from not being a child,
from constant attempts to be like an adult when this was not appropriate
behaviour. Moreover, like other problems of children, the problem of the
solitary child was not restricted in its range of application to particular
children. Any child could suffer from 'only childism' if not properly
reared. 67
All this, however, was not enough: 'Can we produce healthy babies until
we have produced mentally secure parents?... Not until we have had one
or two generations of infants brought up from birth to maturity in
accordance with the best principles of mental hygiene.'68 As early as 1919,

Buzzard, in his Presidential Address to the Section of Psychiatry at the
Royal Society of Medicine, advocated 'rational mental hygiene' and argued
that it should be taught to medical students so that GPs would know of
it. 69 Hcnderson, in his Morison Lectures for 1931, proposed that mental
hygiene should be placed on the same footing as physical hygiene with
centralised control vested in public health officials. Many forms of
disordered conduct were believed due to an individual's inability to adapt
himself to the demands of everyday life 'and a hopeful method of
approach was to deal with those who had not yet developed any
outstanding defect'. 70
Moral education, social responsibility, healthy relationships and happy
marriages would need to be engendered throughout the population. 'The
sense of meaningful community must be re-created at a higher turn of the
spiral.' Social class differences were outmoded, it was argued, and they
needed to be replaced with insight based on friendly participation. 'This
technique applies at all levels, in the home, in education, in industry and in
politics and is essentially the same technique as that used in modern
psychotherapy.' 71
The strategy of mental hygiene could also be deployed in industry:
behind industrial problems were to be found problems of mental function-
ing. In a study by the Industrial Fatigue Research Board, neuroses were
found to underlie telegraphists' cramp. 72 Similarly, the organic lesion of
miners' nystagmus was gradually construed as a neurotic one. 73 Industrial
hygiene, the Chief Inspector of Factories advised, should be taught in
schools and 'workers should be specially kept under observation during
their first year' to see how 'accident-prone' they were. 74
The value of this approach for industry had already been shown by
studies in the USA by Mayo in the late 19205 and by the emergence of the
'human relations' school of factory management. In Britain too, the
deployment of mental hygiene could increase industrial production, relieve
boredom, give pride in work, improve morale, provide incentives, and so
on. 75 Mental hygiene could enable the surveillance of everyone so the misfit
could be identified: 'the socially inefficient, the unemployable, the epileptic,
the habitual offender, the prostitute, and all others who have not been able
to fit themselves harmoniously into the fabric of society'. 76
The new perception over the mind of everyone was at once both a gaze
over the community and a detailed study of the individual. The investiga-
tion of the individual, 'from every aspect, without reference to obsolete and
misleading academic distinctions' 77 , enabled the individual to be classified,
graded and placed in his or her rightful place within the community. 'Once
such a classification is made, a capable medical man is able by appropriate
treatment, to raise many from lower to higher classes ... practical

psychology, with medical co-operation, could also be used for the grading of
young people into classes suitable for different kinds of work.' 78
The Dispensary provided a new technology to ensure that 'square pegs
are fitted into square holes'. 79 A system based on ascription or achievement
could be replaced by one based on observation, tests, interviews, question-
naires, analyses, selection and follow-up. During World War n new
recruits were physically examined for fitness, but it was felt that much more
could be done to weed out the mentally unfit. 80 The new techniques of
personnel selection were applied rigorously to the officer class and it was
recommended that psychologists and psychiatrists could just as profit-
ably be used in monitoring military and civilian appointments in peace-
time. 81
The adoption of this vision of mental health provided a means of
controlling a population - without repression - through constant mapping
and surveillance. But it did more than control: it reordered and restruc-
tured. Personality was 'corrected' by personality82 and the potential threat
to civilisation of latent mental disorder could be constantly counteracted.
The school medical service and the prison medical service, for example,
allowed the doctor to detect 'numerous higher-grade defectives, many of
whom are a menace to the community by reason of their criminal
propensities' 83 GPs could 'have their fingers not only on the pulses of their
individual patients but on the social pulse of the war-time community in
which they live'. 84 From the teacher in the school and the psychiatric social
worker in the community, right up to the suggested expert in psychological
medicine in the Cabinet Office85 , a vast mechanism was proposed to
monitor the mental well-being of the community at a time when every kind
of mental disorder seemed to be on the increase. 86 A community was no
longer conceived of as being fixed and immobile but as being flexible and
malleable; it might be threatened by the very discussion of mental
instability,87 but if reconstituted it might possess undreamed of strengths.
A new psychological medicine

While general medicine showed increasing concern with psychological
matters, such that medical psychology could show 'meteoric' growth, 88
mental hospital psychiatry remained basically opposed to psychodynamic
ideas. 89 Nevertheless, changes in status and in the relationship of
psychiatry to general medicine were signalled by the granting of the
Royal prefix to the psychiatrists' professional organisation the Medico-
Psychological Association in 1926. There were changes too in the per-
ception of the mentally ill, signified by the Royal Commission and
ensuing Mental Treatment Act of 1930 which abolished the term 'asylum'
and replaced the term 'insanity' with 'of unsound mind'
The perceptual structure which had excluded and isolated the insane
had also functioned to separate offtheir attendant medical practitioners. A
conjoining of the insane with other medical patients - either with milder
mental disorder or with physical illness - could serve to legitimate a
commensurate reunion of psychiatry with general medicine.
In 1926 Lord published his The clinical study of menial disorder, in which he
claimed that 'unavoidable circumstances' in the form of legislation had
kept psychiatry and general medicine apart. Now was the time for
reintegration as there were fundamentally 'no sharp divisions between
clinical psychiatry, clinical psychology and clinical neurology'.
'Psychiatry', he argued, 'should be wider than insanity.'90
In 1926 also, Craig published the fourth edition of his Psychological
medicine (with a new co-author, Beaton). In this new edition the separation
of psychiatric from other medical problems was decried: 'insanity is a
separate conception with no real meaning in scientific medicine'. It was
simply a legal rather than medical classification. Problems of behaviour
and mental complaints had too long been separated - they were one
continuum. In consequence, 'mental disorder is increasingly taking place
as a branch of medical science, not to be divorced from but rather to be
more closely linked with general medicine'.91
It was still possible, in the same text, to completely ignore Freudian
explanations in a rewritten chapter on the 'psychoneuroses and the allied
psychoses'. The validity of the Freudian doctrine, however and the
acrimonious discussion which surrounded it - was not the issue. The
important point was that 'the insane patient is ill. He looks ill.'92 Insanity
was a medical problem. Moreover, this reinvigorated psychiatric medicine
of the mind was not just the study of unreason: 'it means the study of the
whole individual ... the patient must be regarded as a biological whole'.93
This new perception of the nature of mental illness was further inscribed
in the new institutional arrangement which emerged to cope with the new
epidemic. The long waiting list for treatment at the Tavistock Clinic in the
inter-war years gave some indication of the iceberg of morbidity which had
been revealed and which required out-patient services.94 Moreover, the
effect of providing adequate out-patient facilities had been demonstrated in
the experimental liaison between the Littlemore Mental Hospital and the
Radcliffe Infirmary in Oxford when the expansion of the out-patient
department for nervous disorders at the Radcliffe had been matched by a
corresponding decline in the population of the mental hospital. 95
The policy of encouraging psychiatric out-patients departments in
general hospitals was endorsed by the Royal Commission on Lunacy in
1926 and embodied in the Mental Treatment Act of 1930. The result was
that more out-patients departments were established, sometimes attached
to teaching or general hospitals, sometimes to mental hospitals. General
and teaching hospitals established their own psychiatric beds96 and
appointed psychiatrists to their staffs (initially often in the department of
neurology).97 Psychiatric training also came to reflect the new divisions
within the psychiatric task. 98
If there is one gesture which can illustrate the sum effect of these changes
in inter-war psychiatry it is in the different worlds of perception signified by
the frontispiece of Cole's Mental diseases, which, from 1913 to 1924, showed
a coloured picture of the diseased brain of general paralysis of the insane, 99
and the dedication of Henderson & Gillespie's Textbook of psychiatry, from
1927 to the present day, to the 'imaginative leadership' of Meyer. 100 In the
former, the ideal of psychiatry was reduced to a simple pathological lesion,
in the latter it was expanded into the meticulous study of individual
'reaction-types'. From that moment, the psychoses needed no longer to be
excluded; 101 psychiatry could embrace 'variations ranging from gross
madness to inconspicuous peculiarities of disposition'. 102 'It is in this
broader, more social, more biological conception that psychiatry today
differs so greatly from its past.' 103
4
A medicine of the social
In 1920 the Consultative Council on Medical and Allied Services of the

Ministry of Health (chaired by Lord Dawson) published an Interim report on
Ike future provision of'medical and allied services 1 In answer to the request by the
Minister of Health to 'make recommendations as to the scheme or schemes
requisite for the systematised provision of... medical and allied services',
the Report offered an integrated concept of health centres and domiciliary
services in which the traditionally separate hospitals would be but one
component.
The Report advocated two types of health centre - primary and
secondary. The latter were basically hospitals, staffed by consultants, to be
integrated with primary health centres. The former were to house and
coordinate all those services in direct contact with the community, such as
the doctor, dentist and health visitor. From this primary level 'difficult'
cases would be referred upwards to the secondary sector.
The proposed primary health centres would integrate all hitherto
separately based domiciliary services, both general practice and municipal.
Thus venereal disease clinics and tuberculosis dispensaries would come
under the same roof and be staffed by the same personnel as traditional
general practice services. The Report consistently stressed the preventive
role of the GP: 'to advise how to prevent disease and to improve the
conditions of life amongst his patients should be an important element in
his work'. The GP would play a valuable part in 'communal services',
ante-natal supervision, child welfare, tuberculosis, venereal disease and
industrial hygiene. He would be 'mainly domiciliary but partly institu-
tional, mainly individual but partly communal'. 2
In total, the Dawson Report advocated an integrated structure
for the formerly disparate elements of health care. From the domiciliary
services in the patient's home to the specialised techniques of the teaching
hospital, the Dawson Report proposed a health care structure which
would effectively embrace thr whole population within its efficient care
machinery.
3-'
A medicine of the social 33
Comprehensive health care

How was it that in a world dominated by independent hospitals the
Minister of Health could charge the Dawson Committee with devising a
'systematised' health care provision? How was it possible to envisage
'comprehensive' health care?
The Dispensary vision, in focusing on the space between bodies, made
possible both the new socio-medical problems - venereal disease, tubercu-
losis, child health, the neuroses, etc., and the special clinics which were
established to survey the social contacts and often transient geographical
manifestations of these mobile pathologies. In this sense the Dawson
Report, in advocating an integrated and comprehensive service, consti-
tuted a further element in an extended disciplinary apparatus. In as much
as the new social diseases and the new manifestations of mental instability
were recognised as occurring everywhere, it was obviously desirable to
deploy new and extensive forms of health care organisation to cope with
these universal epidemics and social threats. A newly constituted social
space required a comprehensive medico-social surveillance.
The Dawson Report also represented, at a more general level, the
unification of separate fields of visibility. Each of the various components of
health care - the new clinics, domiciliary services, general practices and
hospitals - which Dawson enveloped in his proposal for a comprehensive
system, tended to be limited in their powers of surveillance. For example,
the hospital examined the particular bodies in its charge, the school clinic
monitored the children for which it had responsibility and the tuberculosis
clinics could only keep a watchful eye on those in contact with actual cases
of tuberculosis. Within each of these separate medical systems, only certain
patients, or only certain parts of patients, were made visible to the
observing medical authorities; each system tended to possess its own
hierarchies of observation, each its own system of documenting individual
cases.
Yet if a line were drawn to link these separate fields of visibility, to
integrate their separate hierarchies and coordinate their records, then each
single patient and his social space could become more visible, more legible
to the medical gaze. The Dawson Report was therefore a proposal for the
creation of an integrated and open field of medical visibility. The Report
recommended a uniform system of records, throughout the health care
system, based on the card index method. A copy of the record would
accompany the patient wherever he moved and specially appointed officers
would maintain the efficiency of the system: 'such organisation, properly
directed, would be of great value in the promotion of national health'. 3
The National Health Insurance Scheme, of 1911, had instituted a system
of record-keeping for all those patients who had a 'panel' doctor, but,
because this record was returned to the relevant authorities every year, it
was totally inadequate for following through many illnesses. Indeed, such
was the poor, if not non-existent, state of patients records, especially in
general practice, that quite independently of Dawson a Committee had
been appointed by the Ministry of Health to review the whole problem of
medical records. In 1920 it too recommended a new system of record-
keeping which would enable a continuous record of attendance, diagnosis
and treatment to be kept.4
A further manifestation of a more open field of visibility is found in the
emphasis the Dawson Report placed on physical culture. Indeed, one of the
central recommendations of the Dawson Report was for the integration of
physical cultures into the health services. Exercise, it was argued, could
produce 'a healthy and strong body, with balance and grace of movement;
brain control - quick and perfected response and concentration of purpose;
the joy of achievement; discipline, playing for the side rather than self,
loyalty, comradeship'. 5
The linking of physical culture with health may be seen to represent the
conjoining of two influences. The first is that of space. An emphasis on the
space between bodies can be identified in the formal group exercises and in
their outdoor setting which became such a familiar sight in the schools,
parks and open spaces of Europe in the inter-war years. The distinct and
coordinated gestures of arms, legs and bodies reduced the physical
mapping of space to the ritualised movement. At the same time, physical
culture enabled bodies to be observed. Instead of bodies being confined in
homes and hidden by clothing, physical culture enabled them to be
legitimately and publicly viewed. To improve the power of this observing
eye, the Dawson Report recommended games 'which are free or have an
educative design' as well as more formal routine exercises. 'It has been
found that the objects aimed at by a formal exercise can often be attained by
providing the setting of the game, and with the latter there is a spontaneity
and exhilaration absent from the former.'6
Exercise was at one and the same time a means of disciplining bodies and
a means of expressing that discipline. Exercise in the form of'drill' had been
a panoptic device which had been used to good effect in the army to
transform the raw recruit into the disciplined soldier. Similar techniques
were employed in the new schools of the late nineteenth century to cope
with an analogous problem, the disciplining of unruly children. Exercise
had been commended in the Board of Education's 'Suggestions for
consideration of teachers' in 1905, but, following a national outcry against
purely mechanical drill,7 a new technique of 'physical training' which
recognised the subtleties of disciplining impressionable yet varied bodies
was formally advised in the 'Syllabus of physical training for schools' of
1909 and igig. 8 Physical training, the syllabus pointed out, was entirely
different from 'school drill' but it was not total freedom: 'undirected,
indiscriminate exercise cannot take the place of a scientific system of
physical training'; 9 such training, it was felt, would have a physical effect in
improving general nutrition, in development of nerve centres in the brain
and in correcting poor posture and physical inadequacies, but also an
educational effect in developing higher mental and moral qualities. 10
In short, the 'drill' which had emerged with the Panopticon as a means of
analysing individual bodies was replaced by a free yet controlled movement
which analysed the relationship between bodies. The Dawson Report, in
incorporating this controlled movement of bodies into the new programme
of health, further extended the range and power of the medical gaze:
'physical culture is thus concerned with education, with the maintenance of
health and the recreation of the people, and with the curing of disease and
disability, and there is no sharp line of demarcation between these
functions'. 11 An alliance was formally established between the movement of
bodies and a regime of hygiene which in the inter-war years gave rise to
such varied 'leisure' activities as PT, walking, camping, hiking and nudism
and, in the post-war world, to the many bodily exercises undertaken in the
name of positive health.
The Pioneer health centre

The Dawson Report had suggested an important role for the GP in
preventive medicine. Newman, the Chief Medical Officer at the Ministry of
Health, had also felt that while 'all doctors, nurses, midwives, health
visitors, sanitary inspectors and welfare workers should be missionaries of
hygiene', 12 the GP, especially, was 'the instrument, the outpost, the
interpreter', of the new way of health. 13 This perspective was actively
supported by Brackenbury, the Secretary of the British Medical Associa-
tion, who between the wars campaigned vigorously for prevention rather
than diagnosis and treatment - the social rather than the clinical (or
organic) side of general practice. 14
Brackenbury gradually shifted BMA policy from supporting a GP role
which involved 'curing' in hospital, to caring outside. He argued that the
distinguishing feature of a GP case should be home circumstance rather
than the severity of the illness. He proposed intermediate 'home hospitals'
which would enable the GP to be 'transformed from part-time specialists
into part-time social workers'. The GP with his potential intimate know-
ledge of the patient's family and environment, was ideally placed to
monitor the sanitised space of the social. It was to be several decades before
Brackenbury's dream practice became realisable but, in the inter-war
years, at the point of intersection of this vision of a preventive/social role for
the GP, with the open field of visibility as propounded by the Dawson
Report, emerged a unique experiment in health care, namely, the Pioneer
health centre at Peckham. 15
An experimental health centre was first opened in 1926 at Peckham at
which local families were enrolled and given periodic 'health overhauls'.
This screening uncovered much poor health which proved resistant to
treatment. The health overhaul, it was concluded, was therefore ineffective
'in the absence of "instruments of health" providing conditions in and
through which the biological potentiality of the family can find express-
ion'. 16 The first health centre was therefore closed, funds raised, and a
second-stage centre opened in 1935: 'a social structure to be built with a
new unit - not the individual but the family'. 17
In mapping the space created by the interactions of the family, the
Peckham health centre offered a conception of health and illness which was
primarily social. It advocated 'positive' health as against more traditional
'negative' disease definitions: 'health demands a health consciousness and
a health equipment which are distinct and entirely different from the
consciousness of disease and the equipment for dealing with either the cure
or the prevention of disease'. 18 The seeds of disease, it was believed, were
sown in 'disfunction' [sic] and disability and these two major disturbances
were caused by events in the field of social health. 19 The centre provided no
treatment, it was a 'health service of a purely advisory order' 20
An ideology of health promotion required new medical techniques and
these were provided in screening and surveillance. Families had to undergo
three screening procedures enjoining the centre. A laboratory and physical
examination was followed by a 'family consultation' in which the family
was interviewed as a whole unit. The family consultation was found to be
especially useful for families on the threshold of change, such as marriage or
an impending childbirth.21 Community surveillance was effected by a novel
arrangement. Unlike the other manifestations of the Dispensary in the early
twentieth century the Pioneer health centre did not radiate out into the
community; instead, it brought the community within its own walls. The
social club, which formed such a vital role in the life of the centre, with its
attendant games, sports and social activities, acted as both incentive for
patients to join the centre and also as a means of surveillance, not the
examination of the formal consultation, but the unno'ticed silent observa-
tion of patients' spontaneous social activity.22
These two facets of the Dispensary - disease perceived as a social
phenomenon and community surveillance - were, of course, two sides of
the same coin. Surveillance discovered disease in the community and this
discovery necessitated further surveillance. In effect, the Pioneer health
centre destroyed the old distinction between those who were healthy and
those who were diseased. Whereas for traditional hospital medicine, illness
was a deviant status, to the Dispensary, as found at Peckham, it was
normal. If everyone had pathology then everyone would need observing.
Thus of everyone attending the health centre only 7% were found to be
truly healthy.23
The idea that everyone was ill was an important element in the operation
of a generalised surveillance. The new social diseases of the twentieth
century, tuberculosis, venereal disease and problems of childhood, had
been reconstrued to focus medical attention on 'normal' people who were
nevertheless 'at risk'. This same notion can also be seen in the discovery of
the neuroses which, at least in mild form, came to appear in almost
everyone. The innovations of the Peckham centre effectively extended this
principle to more traditional organic diseases by dissolving the clear
boundary between the healthy and the diseased. This process was to be
continued after World War 11 with the discovery, on the one hand of the
'clinical iceberg' by epidemiologists24 and, on the other hand of 'illness
behaviour' by medical sociologists. 25
From the institution of a social club to the design of its buildings, every
development within the Peckham centre was a conscious attempt to make
visible the web of human relations. Every change, every improvement was
made with the deliberate aim of extending the observing eye. In 1936, for
example, a nursery was added to the facilities: it enabled 'the doctor to
make continuous observations on the child in the normal environment'. 26 A
special key for use by patients was also designed (though never installed).
The key would give access to the building for each individual of every
member-family and it would also enable them to gain access to particular
facilities within the building. The key, however, was to function in two
ways: on the one hand, it would give freedom of access and movement to the
patients; on the other, it would enable a record to be kept of these precise
comings and goings: 'suppose the scientist should wish to know what
individuals are using the swimming bath or consuming milk, the records
made by the use of the key give him this information' The key would at
once be important 'for dis-embarrassing the observer of duties connected
with control' and 'desirable for freeing the individual member'. 27 Greater
freedom could only be met by more invisible and pervasive observation.
'The general visibility and continuity of flow throughout the building is a
necessity for the scientist.' 28
The Peckham experiment was a laboratory for the development,
refinement and deployment of new technologies of observation. At
Peckham, individual bodies and their relationships yielded to a clearer field

of visibility. 'In the biological laboratories of botany and zoology the
microscope has been the main and requisite equipment. The human
biologist also requires special "sight" for his field of observation the
family. His new "lens" is the transparency of all boundaries within his field
of experiment.' 29
Social medicine
Following a distinguished career as a consultant physician at Guy's
Hospital, John Ryle reached the pinnacle of medical success when he was
appointed to the Regius Chair of Physic at Cambridge. In 1943 he resigned
this position to become the first Professor of Social Medicine at the newly
established Institute of Social Medicine at Oxford.
Social medicine was a new discipline. There had been other forms of
social medicine and hygiene but these, as Ryle pointed out, had restricted
themselves to various 'deviant' groups, whereas the new social medicine
was not so confined. 30 The new social medicine was concerned with the
study of people in groups; in particular it searched for social pathology. It
embraced 'on the one hand the whole of the activities of public health,
administration and of the remedial and allied social services, and on the
other the special disciplines necessary for the advancement of knowledge
relating to sickness and health in the community'. 31 Hence its important
component disciplines were social pathology and hygiology ('the study of
health and its causes'). 32
Ryle pointed out that he had spent some 30 years in clinical medicine and
during that time disease had been more and more elaborately investigated
by mechanical means, to the exclusion of the social domain. The new age
had to redress the balance: a new concern with prevention, social pathology
and health in the round. 'I submit that we can only do this effectively by
electing to pursue the study of social man in sickness and in health.'33 The
new social medicine created an alliance between the old discipline of public
health and the new manifestations of the Dispensary, thereby extending the
interests of public health from concern with the environment to a concern
with social relations.
In its recommendations of 1936 the General Medical Council stated that
the medical student should be directed throughout his course to the
importance of the measures by which 'normal health' could be assessed and
maintained and to the principles and practice of the prevention of disease.
In the late 19308 the term 'social medicine', which had previously been used
as a general name for municipal health services, came to describe the new
discipline which incorporated preventive medicine, public health and a
focus on social relationships. Such was the interest that this new subject
quickly engendered that the Royal College of Physicians appointed a Social

and Preventive Medicine Committee in 1942 'to consider the subject and
make recommendations for its development'. An interim report appeared
in I943. 34
The report pointed out that preventive medicine under the rubric of
public health or hygiene was already in the undergraduate medical
curriculum, whereas social medicine, in examining the social environment
and heredity as they affected health and well-being, represented 'a
relatively novel point of view'.35 The Committee thought that social
medicine constituted the background for _ both preventive and curative
medicine and that it was important enough to justify completely reorganis-
ing the curriculum to give it its due place. The potential range of social
medicine was so broad, however, that much of it would have to be taught -
and quite appropriately - in other departments. The obstetrician should
teach the preventive as well as the clinical aspect of his subject, as would the
paediatrician, the venereologist, the specialist in tuberculosis and the
psychiatrist.36
An important place in the teaching of social medicine was suggested for
the hospital almoner. From an inter-war role of assessing patients' financial
means and their ability to contribute towards the cost of treatment, the
almoner became caught up in the new task of social investigation and was
gradually transposed into the familiar role of the social worker. 37 As a
figure, therefore, who emerged from the social domain to police the social,
the new hospital almoner was ideally suited to teach social medicine to
medical students.
These various suggestions were echoed by the Inter-Departmental
Committee on Medical Schools, chaired by Sir William Goodenough,
which was appointed by the Minister of Health in 1942 to make
recommendations on medical education. A Report was published in 1944
which endorsed most of the recommendations of the Royal College of
Physicians' Committee. 38 The Goodenough Report also recognised that
social medicine was not restricted to preventive medicine: 'It signifies a
particular conception of Medicine; a conception that regards the promotion
of health as a primary duty of the doctor, that pays heed to man's social
environment and heredity as they affect health, and that recognises that
personal problems of health and sickness may have communal as well as
individual aspects.' Such a view was receiving increasing support, it was
argued, from the medical profession and the general public. 'There is
growing support for the view that a general medical practitioner should
become the health advisor of his patients and their families and should
participate to a greater extent in the conduct of the health services of the
country.' 39
The ideas of social medicine, it was suggested, should 'permeate the
whole of medical education'. This would necessitate a fundamental
reorientation of that education and of the outlook and methods of most
teachers. Anatomy and physiology should not be taught solely such that, by
contrast, the pathological could be understood; the study of the normal was
important in its own right in the promotion and maintenance of mental and
physical health. In the clinical years it was insufficiently recognised that 'in
the study of the patient's life as a whole may often be found the reason for his
illness and the only key to the restoration of his health. If students are to
acquire the right outlook they must see their teachers enlisting the help of
almoners, psychiatric social workers, health visitors and other welfare
workers, and considering clinical problems against the background of the
patient's domestic circumstances and environment.'40
The existence of such a social medicine and its various characteristics-
concern with the normal and positive health, with screening and social
relationships was a manifestation of an analysable social space between
bodies. It was, therefore, at the same moment as a medicine of the social
was born that a politics of the social became a possibility. European society
throughout the inter-war years was a 'mass' society on which the politics of
socialism played in all its varied forms.
If, at the beginning of the nineteenth century when the various elements
of the discrete and autonomous body were being fabricated by the panoptic
gaze, the ideal project and terrifying dream was signified by Frankenstein's
monster, then in the inter-war years it is perhaps Orwell's 1984 or Huxley's
Brave new world which best express the new configuration of power. The
discipline-mechanism, as Foucault clearly states, is 'a functional mechan-
ism that must improve the exercise of power by making it lighter, more
rapid, more effective, a design of subtle coercion for a society to come'.41 Yet
how could Orwell's and Huxley's futuristic Utopias, which demanded a
constant surveillance, a calculated control and the final eclipse of the
individual body by the all-pervasive social, be realised either politically or
technically?
The solution to this problem emerged during the war at a point when it
became politically possible to create an exhaustive surveillance machinery.
In the armed forces, where fighting efficiency had to be sustained, an
experimental ground was created for the emergence of new techniques of
observation. As Crewe, Professor of Public Health and Social Medicine in
Edinburgh and a brigadier in the army medical service acknowledged, 'the
Army with its all-in system of medical inspection and care has provided
unique opportunities for the rapid development of social medicine'.42 In the
army, health promotion and disease prevention had to be coordinated with
and seen in the context of other functions such as planning, organisation,
welfare, training, etc. Thus, from the outset, social medicine in the army
'demanded for its development a corpus of knowledge concerning occupa-
tion, locality, social amenities, personal habits, aspirations, risks and
responsibilities': in short, a science of human ecology. 43
On the domestic front, the war gave 'a new impetus to all forms of health
education' as the Chief Medical Officer to the Ministry of Health
reported. 44 Increased publicity was given to health and it could be claimed
that 'more than ever before, health, in contradistinction to disease, is news,
and prevention is acquiring some of the drama of cure'.45 Yet, while a
medicine of the social was promoted by a war-time need to know and make
visible the social networks of the community under threat, it was also the
product of another movement which acted to reinforce the Dispensary
system of community surveillance and make its workings far more efficient.
That new development was to be found in the invention of the survey.
5
Technologies of the survey
In 1839 the Poor Law Commissioners were given the task of surveying the
sanitary conditions of the 'labouring classes'. Data were gathered from
boards of guardians, medical officers of unions and general practitioners
and published in 1842 as a Report on the sanitary conditions of the labouring
population of Great Britain. In 1851 the Census in England and Wales made
an attempt to count the number of blind and deaf and dumb in the
community and the number of lunatics in asylums. Both these surveys
represented attempts to gain knowledge of aspects of the population but
both were limited. The Poor Law Commissioners' survey relied mainly on
qualitative data, as did later surveys such as that of the Health of Towns
Commission of 1844. The Census, on the other hand, obtained quantitative
data but under-reporting was recognised as a serious problem, especially
after 1871 when questions on whether imbeciles, idiots or lunatics lived in
the household were introduced.
Further refinements in survey technique were made in Booth's Life and
labour of the people of London: 1892-1903, in which information, including data
on sickness, was obtained through the agency of the London School Board
visitors on every family in 3400 London streets. Rowntree's survey of
poverty in York, which commenced in 1899 dispensed with intermediaries
and gathered data directly from respondents. A survey of poverty by
Bowley in five provincial towns in 1912 introduced sampling by selecting
one in twenty households, at equal intervals, from a complete list. Thus, by
the second decade of the twentieth century, sufficient techniques had been
developed to make the survey an efficient instrument for the investigation
and measurement of populations. 1
The Dispensary had emerged in the same years as survey methodology
was refined, early in the twentieth century. The Dispensary mapped both
geographical and social space and therefore functioned as an apparatus of
surveillance. In its ceaseless monitoring of the community, it represented,
in somewhat rudimentary form, a survey. The possibility therefore arose of
fusing the particular techniques of surveillance that had been developed in
survey methodology with a system of disciplinary power that was embodied
42
Technologies of the survey 43
in the Dispensary. The survey, a mechanism for 'measuring' reality, could
be transformed into a technology for the 'creation' of reality; the tactics of
the survey could make the operation of disciplinary power throughout a
society more effective and more efficient.
Foucault points out that a menagerie had been constructed at Versailles
in which a central room, the king's salon, looked out onto seven cages
containing different species of animals so that the king, from a single
vantage point, might oversee his animal collection. 2 It would thus seem
that the particular architectural structure that Bentham succeeded in
marrying to a system of power was already in existence before the invention
of the Panopticon. Similarly, during the early decades of the twentieth
century, a mechanism for the investigation of communities, in the form of
the survey, existed side by side with a device (the Dispensary) which
enabled the gaze to be deployed throughout the community, without the
one assimilating the other. Indeed, when survey techniques were finally
harnessed to the Dispensary, it was not because it was realised that the
survey might improve the efficiency, range and invisibility of the mechan-
isms of power as embodied in the Dispensary; that discovery was to come
later. The interest of the Dispensary in survey techniques arose in the
inter-war years from its central concern with the normal.
The normal control

The idea of the norm Was, as Foucault argues, a particular invention of the
Panopticon. 3 The examination of bodies involved the approximation and
comparison of each body with the 'normal' since the Panopticon was
concerned to identify deviants who failed to measure up to the norm. The
distinction between those who met the norm and those who did not was,
however, absent from the Dispensary. Instead of being an arbitrary
external referrent, the normal came to be located within the social body
itself: bodies themselves defined normality. A central element in the
functioning of the Dispensary came to be the rejection of'the norm' and the
focus on 'normal variability'.
In 1930, Thomas Lewis had commended to his colleagues the value of
'clinical science'.4 He argued that medicine, through the exaggerated
importance it attached to diagnosis, had come to over-depend on techni-
ques of clinical observation. In the part these techniques had been valuable
and had led to major advances, but, as Lewis observed, 'eventually the
fertility of this method greatly declines by a process of exhaustion, and, for
those who can read the signs, this time has come in medicine'. 5 In place of
the observational method, Lewis proposed clinical science which would use
the experimental method.
The clinical science campaign, which, from 1930 onwards,was actively

promoted by Lewis, placed the body of the patient in a new context. Lewis
challenged the norms by which the body had been defined. Curative
medicine, he argued, dealt with the individual while clinical science, or
'progressive medicine', was collective in its outlook. To the latter the
patient was 'but an incident ... one who exhibits phenomena of disease to
be compared and correlated with those displayed by other subjects'. 6 In
effect, the normalising judgement of the clinical gaze, in this new
progressive medicine, would not use 'the norm' as a referrcnt but instead
placr the body of the patient in the context of 'other subjects' and then
measure the differences.
The comparison, moreover, was not only with other patients, but also
with the healthy. In the past, the pathological or the abnormal had stood in
opposition to the physiological or normal. In clinical science, however,
applied physiology was used to explain the pathological: in other words,
explanation by reference to the normal came to invest the explanation of the
abnormal. The possibility of a relational medicine was explored as the body
of the patient was analysed in juxtaposition to other bodies, both healthy
and sick.
At the same time as the body of the patient was placed in its new social
context, it also, through the identification of particular differences, became
further individuated. Lewis, for example, argued that in certain situations
the patient need not be compared with the healthy but with himself: 'You
may study heart failure by comparing normal subjects with those who show
failure. It is not the same thing; it is the chance of minutely comparing the
normal and the abnormal states of circulation in one and the same subject that is
so important: here is the perfect control.'7
Use of the patient as his own control - which furthered the constitution of
a relational medicine - can also be seen in the emphasis given to the
physiological basis of symptoms. Symptoms, from being the subjective and
therefore unreliable component of the diagnostic process (signs being
objective), were examined in the context of physiological processes: 'the
study of symptoms necessitates very close consideration of the relevant
mechanisms of the body while this is working naturally'.8 The patient,
instead of simply describing the occurrence of symptoms, was asked to
come under observation while the symptom was 'provoked' and changes in
body functioning monitored and observed.
This close examination of the apparently pathological, in the terms of the
physiological, produced anomalies. Ryle, for example, in investigating the
physiologically normal of the population, had discovered that 10% of fit
medical students showed gastric acidity which would previously have been
regarded as abnormal. 9 As Ryle was later to point out, this led him to
believe that 'a similar variability may be demonstrated or assumed in

respect of all measurable physiological activities and of other immeasurable
physical, mental, and emotional states and processes'. 10
These problems in the variability of normal and disease states were
particularly pertinent to therapeutics. The success of many established
therapies was based on the 'post hoc ergo propter hod fallacy whereby the
natural course of the disease was mistakenly attributed to the treatment.
But what was the natural or normal course of a disease? Clinical science
could in part answer the question by observing the common features in the
natural histories of various diseases but this rarely had predictive value in
therapeutics.
In the 19308 the 'post hoc propter hoc1 fallacy was placed in a new context:
not simply as the adage of the sceptical clinician but as a part of a strategy
which sought to examine the natural or normal course of disease. Hence
there emerged the two great twentieth-century inventions of therapeutics,
the placebo and the control. The concept of the placebo emerged in medical
discourse in the context of the apparent efficacy of pharmacologically inert
substances; the 'normal' control became the referrent for pharmacological
activity in the body of the patient.
Shapiro has traced the first use of the word placebo, in its current medical
sense, to the beginning of the nineteenth century. 11 However, the term was
used so infrequently that Wood's Therapeutics, whose fourteen editions
covered the period from 1875 to 1908, never indexed it. 12 Indeed, Shapiro
has been able to discover only one medical paper between 1900 and 1930
which actually used the word and that paper was primarily about ethics.
Between 1930 and 1950 there were seven papers about the placebo effect and
between 1950 and 1957 some 48 papers which in some way discussed it.
This growing interest in the placebo effect can be seen to have arisen at
the point of intersection of several influences. Firstly, the placebo, unlike
the active drug, did not in principle interfere with the natural or normal
course of the disease: it was therefore of value to a clinical gaze which sought
to examine the normal. Secondly, the placebo effect was seen as having
great power itself because it unlocked the power of individuals over their
own bodies - this latter being the essence of the disciplinary power of
panoptic and Dispensary visions. Thirdly, an interest in the placebo led
both to the importance of having 'normal' controls in therapeutic trials and
to the use of placebos within those trials. The history of the controlled
clinical trial, as well as being a record of therapeutic improvement, can also
be read as the refinement and development of an analysis of the normal
patient in the context of a disciplinary apparatus.
In 1931, the Medical Research Council created the Therapeutics Trial
Committee to test under 'controlled conditions' the efficacy of new drugs
developed by companies in the British Association of Chemical Manufac-

turers. During the 19305, various therapies were tested under the auspices
of the MRC and by 1943 the Lancet could write: 'Our experience of the last
few years proves that writers on clinical subjects are more figure conscious
than their elder brothers. It is less common to find startling conclusions
from (say) six cases.' 13 A year later, after a well-controlled trial of patulin in
the common cold had shown no significant difference between control and
experimental groups, the Lancet concluded that the lesson of the enquiry
was that 'no remedy for colds must be judged until it has been submitted to
a large scale trial' 14
The study, often judged the most important of these early researches, was
that of the MRC trial of streptomycin in tuberculosis. 15 The first trial of
streptomycin in tuberculous meningitis did not use controls as the infection
was invariably lethal. 16 However, in the second part of the trial, to test the
effectiveness of streptomycin in pulmonary tuberculosis, untreated controls
were added as the course of the disease was unpredictable. 17
The British MedicalJournal devoted a leader to this 'controlled therapeutic
trial' an idea, it thought, 'recent enough to call new'. In describing the
design of the investigation, the Journal was at pains to reaffirm the integrity
of the radiologists who had read the x-rays not knowing from which group
the patient had come: 'it in no way questions the intellectual honesty of the
investigator who is thus asked to work "blind"'. 18 The Lancet thought the
study was brought 'as near to a laboratory experiment as is practicable and
makes it unique in the dismal history of tuberculosis chemotherapeutic
trials'. 19
The invention of the controlled clinical trial, in which the normal
population became the referrent for monitoring the course of disease in
individuals,20 also necessitated the development of appropriate statistics
for comparing experimental and control groups. In 1937 the Lancet had
invited Bradford Hill to prepare a series of articles on basic medical
statistics, as it was felt that the medical profession was insufficiently
conscious of the need to express its findings in number and was often
unaware of the importance of taking into consideration unknown and
uncontrollable variables. 21 Following its success, the series was published
as a book later that same year.22
The development of statistical methods and the concept of the normal
control population also released epidemiology from its 'experimental'
cul-de-sac. Earlier in the century, Greenwood & Topley had revived a
quiescent epidemiology with an experimental approach.23 The focus of
these early twentieth-century epidemiologists was not so much the infective
danger of the environment but, like that of so many disciples of the
Dispensary, the health dangers of social contact. Experimental epidemi-
ology was, therefore, concerned with 'crowd diseases' and the study of the
transmission of diseases throughout populations. 24 Rats and mice were
used to simulate the vagaries of human relationships, over-crowding,
distances, proximities, etc., and precise mathematical summaries were
devised, especially of the 'epidemic wave', to express the path of infections
as they were passed from animal to animal through the colony.25
The invention of the human control population enabled epidemiology to
focus once more on human populations and the 'experiment' to be
reproduced in patients. The case-control study, in which the sick are
compared (usually retrospectively) with control cases, was used by
Lane-Clay ton in the 19203 to study the outcome of treatment of breast
cancer. 26 But perhaps its best-known early use was in Doll & Hill's work,
published in 1950, linking lung cancer and cigarette smoking. 27
The effect of the normal control was to place the patient and his disease,
treatment and prognosis, in a social and conceptual space which encom-
passed the social body. There was not a hospital wall between the ill and the
community but a measurable and calculable gap and it was, increasingly,
only by placing the patient in a field invested by the normal (derived from
the social body) that the patient could be either known or constituted. The
corollary was that the social body itself had to be further made visible and
subject to the clinical gaze.
Knowledge of populations was promoted by further refinements in
recording techniques in the inter-war years. The Medical Research
Council, for example, had devised special charts for its inter-war School
Epidemic Investigation which enabled the movement of disease within a
population to be recorded, and Pickles, the Wensleydale GP, used a
modified version of these same charts for his now classic observations on the
course, natural history and distribution of various diseases in the ig3os. 28
Mechanical tabulation of hospital records was developed and in 1936
Spear & Gould suggested it now provided a 'powerful agent in the hands of
the investigator. In this direction we feel that the almost limitless
possibilities of the system have not been and are not realised.' These
techniques, they felt, would also be applicable to surveys of disease in
populations.29
The Nuffield Trust had funded a Bureau of Health and Sickness Records
to undertake morbidity studies in the Oxford region. The Bureau devoted
considerable energy to 'developing and standardising better recording
systems for use in research departments, hospitals and the public health
service'. 30 In 1943, under the new Institute of Social Medicine at Oxford, it
attempted to measure total morbidity in the population, using both
hospital and GP records.
A classification of morbidity was also developed through the Nuffield
Provincial Hospitals Trust and the Editorial Board for the Official Medical
History of the War. A special MRC Committee was appointed which
checked the in-patient records of the emergency medical service hospitals
and from them developed a classification system which enabled morbidity
data on all military personnel entering the EMS hospitals to be coded and
card indexed. 31
The focus of these improvements in coding and recording techniques was
twofold: on the one hand, they offered a chance to assess the natural course
of disease in the population, unencumbered by medical intervention, and,
on the other hand, then enabled the normal to be more fully investigated.
Ryle summed up the central problems with the title of his essay 'The
meaning of normal and the measurement of health'.32
Whereas disease could be observed in separate individuals, health was a
concept that could only be constructed from populations. Yet such was the
range of normal, as Ryle pointed out, that 'only in living samples of
sufficient size can we usefully observe in juxtaposition and compare the
manifestations of health and sickness and borderline states'. The source of
these living samples could not be the hospital ward but must be the 'welfare
centres and nurseries, in schools and universities, in the armed forces, or the
large communities'.33
The focus on the wider community, which characterised the Dispensary,
was considerably enhanced by the war. The war presented a community
under threat; a community which had to be united behind the war effort
and at the same time monitored for potential weaknesses; a community
which had to be analysed to see whether its strengths and resources were
being adequately used. In short, the perception of the problems of war-time
created problems of social threat similar to those faced earlier in the century
by the reformers in the midst of epidemics of tuberculosis and venereal
diseases. Here was a problem which demanded an improved rigour in the
disciplinary mechanisms of the society: this need was met by the
deployment of a new technology, namely, the medico-social survey.
Surveillance by the survey

It would be inaccurate to argue that the medico-social survey was invented
during the war. Such surveys had been conducted during the nineteenth
century, though the development of adequate quantitative methodology
had not occurred until early in the twentieth century. Thereafter,
occasional surveys had been conducted. Some of the earlier studies were
repeated: Bowley repeated his 'Five town survey', of 1912, in 1923-4; the
London School of Economics conducted a survey in 1928 some three
decades after Booth's pioneering work - entitled New survey ofLondon life and
labour1 , and the University of Liverpool, in 1929, produced the Merseyside
survey which included aspects of illness in the community. 34
The newly created Ministry of Health had resolved, in 1920, to use
survey techniques in the elucidation of problems of public health in the
same way as had nineteenth-century investigators. 'We must pursue this
method ... but we must make our surveys more comprehensive.' 35 A study
on the incidence of rheumatic diseases based on data collected from a group
of insurance medical practitioners was published in ig24. 36 Surveys of the
adequacy of public health services in different countries were inaugurated
following the Local Government Act of 1929. 37 In 1933, researches were
commenced into the nature of the diet in different parts of the country, the
results of studying the diets of 69 working class families in Newcastle being
published in I936. 38 The effect of the 'normal' diet was also analysed by
haemoglobin level surveys. Haemoglobin levels were measured in school
children in Manchester, Warrington, Barnsley and Huddersfield and levels
in pre-school children and their mothers were established in Warrington,
Barnsley and Leeds. 39
Other attempts to survey the community - though often without formal
survey techniques - were also made in the inter-war period. The Pioneer
health centre at Peckham had attempted to map the health of its population
during the 19305 by careful recording, monitoring and surveillance. 40
Madge & Harrisson had founded Mass Observation in 1937 with the
express purpose of providing a voice for the ordinary member of the
community. Amateur 'observers' were appointed around the country 'to
describe fully, clearly and in simple language all that he sees and hears in
connection with the specific problem he is asked to work on' 41 These
various surveys and quasi-surveys, however, supplied only limited and
unclear pictures: it was the advent of the war that created the conditions for
a greater visibility and a concomitant, more penetrating and unified gaze,
over the whole community.
The war-time community presented various social problems, among
them dislocation of labour, war injuries, evacuation, nutrition and
rationing. If the war was to be won, a firm grasp had to be taken over the
nation's functioning. And if medicine was to play its part in this great effort
then it would have to provide medical services for the whole population and
know more about the distribution and extent of medical need. As
Langdon-Brown argued: 'What is needed is a complete sequence of medical
supervision throughout life.'42
In 1940 the Ministry of Information, through the National Institute of
Economic and Social Research, created a 'public opinion testing machine'
called the War-time Social Survey. 43 The Lancet pointed out that such 'new
methods of studying the population would be helpful, not only in planning
legislation but also in watching the effects of totalitarian war on the

community as a whole'.44 The War-time Social Survey offered 'direct
access to the raw material of government, the people themselves'.45
Random samples of the population were interviewed for their knowledge
and attitudes towards various subjects. Members of the public were found
'willing, and even enthusiastic' to provide information. 46 The government
could, therefore, at one and the same time know the effect of food publicity,
the attitude to news broadcasts, the fact that 67% of the population
believed the purpose of the war was to protect liberty and freedom, 6% to
save civilisation and that 2% expressed 'cynical views'. 47
Knowledge of public opinion could then be integrated with other surveys
of the population. A network of surveillance, for example, began to be
constructed to make visible the nutritional state of the community. The
Chief Medical Officer at the Ministry of Health later contended: 'In order
to be able to advise on matters of nutritional policy it was necessary for the
Ministry of Health to keep a continuous watch on the nutritional state of the
people.' 48 In 1940 the Ministry of Health revived the dietary surveys of the
19305 on a regular basis; a clinical survey of malnutrition was conducted in
1942; the Medical Research Council commenced community surveys of
blood haemoglobin; a survey of the height and weight of 12000 children
was carried out in 1940; a controlled trial of the nutritional value of
supplementary vitamins was carried out in 1940 on 2500 school children.49
In the past, government departments had collected some statistics by
means of a return. These 'returns' were limited in scope, slow to collect and
remained uncoordinated between different departments. The survey drew
together these incidental statistics into a coherent map. Departments could
supplement their statistical returns and relate one set of data to another by
sample surveys. 'There is no doubt that in this way a most flexible
instrument for the compilation of a wide range of statistics can be
developed.'50
It became possible to coordinate hospital data. Between 1940 and 1946
every fifth patient in the emergency medical service was coded. The
Medical Research Council provided a Provisional Classification of Dis-
eases and Injuries, in 1943, to enable appropriate codings of morbidity51
and in 1949 this procedure was formalised in the Hospital In-patient
Morbidity Survey.
But what of the general health of the community? There had been reports
of a great increase in minor morbidity and of over-crowded general
practitioner surgeries. 52 In 1944 the Social Survey was extended to
encompass the perceived health of the population. A random sample of the
civilian population was regularly interviewed at two-monthly intervals
about their health in the preceding three months. The results provided
constant information about the extent - and changes - of illness in the

population and data on use of medical services. 53 The government was thus
able to monitor the health of the population in regularly up-dated health
indices and the Chief Medical Officer at the Ministry of Health advocated
further studies. There was a need for surveillance of pregnant women:
perhaps this could be possible through providing detachable slips in ration
books? There was, moreover, a need for a 'statistical framework linking
maternity, paediatrics and school medical services to one another and to
adult health services'.
The comprehensive surveillance network that the survey deployed
throughout the community should not be interpreted as simply a device for
social control. Certainly, in as much as it was a disciplinary apparatus it
was concerned with ordering a population, but this was only one
component of its overall functioning. The survey was also an apparatus of
normalisation. It deliberately sought out the normal population and
measured it. The survey, as Ryle was to argue, was a means of measuring
the health and illness of the 'total person' Doctors had for too long made
judgements based on constant association with sick people and advanced
disease; most lacked 'the experience of examining large numbers of
ostensibly healthy children, adolescents, or adults'. He therefore proposed
the medical examination of large, randomly selected populations, measur-
ing height, weight, haemoglobin, blood pressure, pulse-rate, x-ray, person-
ality, intelligence, skin complexion, fatness, adaptability, etc. 55
In effect, the survey established the possibility of removing the abnor-
mal/normal divide. The survey classified bodies on a continuum: there were
no inherent distinctions between a body at one end and one at the other,
their only differences were the spaces which separated them. The referrent
external to the population under study - the norm - which had for almost
two centuries governed the analysis and distribution of bodies was replaced
by the relative positions of all bodies. The survey was a synthesised gaze to
relationships, to the gaps between people.
Like the Panopticon, the survey was therefore a two-edged sword. It was
an instrument of order and control, a technique for managing the
distribution of bodies and preventing their potentially dangerous mixings.
On the other hand, this ordering required the identification of relationships
through the confession of the body. Illness was no longer the preserve of the
medical profession but of the body's own perceptions; the body had to
speak, not of some abstract pathological theory of illness, but of immediate
feelings. Thus, while the survey became increasingly concerned with the
'objectification' of personal experience through its constant measurement
and analysis, it must not be forgotten that those same personal experiences
were a fabrication of the creative component of the survey which demanded
6
Disciplines of the survey:
1. child life and health
In establishing a new political economy of power the Panopticon had

created a conceptual domain and an architectural space which required
policing. During the early nineteenth century a unified medical profession
emerged to take on this role. In similar fashion the extensive deployment of
the survey in post-war medicine produced changes and realignments in
both the form of medical knowledge and the organisation of the medical
profession.
Perhaps, when the history of the sociology of the medical profession
comes to be written from post-war sociological texts and journals, the
apparent diversity of analytical perspectives - from liberal to repressive -
will be seen to be simply different components of an overall system of
disciplinary power. 1 Equally, the diversity of views which have character-
ised the explanation of medical specialisation ('an inevitable and desirable
accompaniment of medical advance', through to simply a device for
professional advancement2 ) can be embraced in an analysis which
examines, not medical knowledge, but its object. It is the gaze which at
once unifies medical knowledge and maintains its fragmentations. The
various specialties which have emerged, surgical, medical, pathological,
investigative, far from being somewhat 'random' events, 3 all relate to
aspects of the detailed examination and analysis of the body: in short, the
panoptic vision is inscribed into the very structure of medical knowledge
and its social organisation. Thus when the survey established new zones of
visibility it thereby created the space for the observing gaze of new
disciplines.
Surveys of childhood
In 1940 there were two medicines for children. First, there was the direct
manifestation of the Dispensary as found in child welfare clinics milk
depots, nursery schools, the school medical service, etc., which monitored
the community and spread %thc new hygiene. 4 The second was the relatively
new specialty of paediatrics, a direct outgrowth of clinical medicine 5
54
Disciplines of the survey: 1. child life and health 55
An interest in diseases of children had been shown by some general

physicians from the late nineteenth century. 6 This specialist interest was
justified in the main by the apparently peculiar presentation of various
diseases in childhood. Forsyth expressed this view in his Children in health
and disease, of 1909, when he stated: 'With few exceptions the pathological
processes of youth and of maturity are alike ... clinical effects however
differ.'7 The name given to the Society for the Study of Diseases in Children,
founded in 1901, signified the subsidiary position of the child relative to the
disease. Hutchinson, one of the first general physicians to take an interest in
diseases of childhood, confessed that had his practice been solely restricted
to children his knowledge of children's diseases would have been 'poorer
and meaner' 8
With the child as an object of increasing concern, and the invention of the
'problem child' in the early twentieth century9 , the medical gaze shifted
towards the diseases peculiar to children rather than the unusual mani-
festation of'adult diseases' in children. The British Paediatric Association,
founded in 1928, was born of this view and by the 19403 it had become the
rule rather than the exception for physicians in the diseases of children to
confine themselves to that specialty. In effect, a mere side-interest of
general physicians became a specialty in its own right through the
elaboration of childhood and childhood relationships. Yet the focus on
childhood remained essentially a focus on a figure in the Panopticon, in that
inter-war paediatrics reproduced the cognitive and organisational forms of
its parent medical discipline. Meetings, for example, at the Section for the
Study of Diseases in Children, and research reported in Archives ofDisease in
Childhood, were all wholly concerned with the examination of the character-
istics of the individual case. 10
A major realignment in paediatrics began to occur during World War n
when the paediatrician's gaze shifted from the child as a figure in the
Panopticon to the child in the community: children were evacuated; food
for children was in short supply and the threat of malnutrition loomed;
children were stressed by disruption of families and loss of parents. The
problem was no longer the place of the disease in its nosology but of the
child in its community and social context. As Jameson, Chief Medical
Officer at the Ministry of Health argued 'in the past paediatrics had shown
too little interest in child development and had rather confined their
attention to the sick child'. 11 The techniques of the public health child
health services ('periodical medical examination coupled with surveillance
of a less formal kind' 12 ) would now need to be learned and deployed by a
community orientated paediatrics.
During the war, paediatricians meeting at the Royal Society of Medicine
increasingly discussed the problems of the child in the community.
6
1. child life
\j and health
In establishing a new political economy of power the Panopticon had

created a conceptual domain and an architectural space which required
policing. During the early nineteenth century a unified medical profession
emerged to take on this role. In similar fashion the extensive deployment of
the survey in post-war medicine produced changes and realignments in
both the form of medical knowledge and the organisation of the medical
profession.
Perhaps, when the history of the sociology of the medical profession
comes to be written from post-war sociological texts and journals, the
apparent diversity of analytical perspectives - from liberal to repressive -
will be seen to be simply different components of an overall system of
disciplinary power. 1 Equally, the diversity of views which have character-
ised the explanation of medical specialisation ('an inevitable and desirable
accompaniment of medical advance', through to simply a device for
professional advancement2) can be embraced in an analysis which
examines, not medical knowledge, but its object. It is the gaze which at
once unifies medical knowledge and maintains its fragmentations. The
various specialties which have emerged, surgical, medical, pathological,
investigative, far from being somewhat 'random' events, 3 all relate to
aspects of the detailed examination and analysis of the body: in short, the
panoptic vision is inscribed into the very structure of medical knowledge
and its social organisation. Thus when the survey established new zones of
visibility it thereby created the space for the observing gaze of new
disciplines.
Surveys of childhood
In 1940 there were two medicines for children. First, there was the direct
manifestation of the Dispensary as found in child welfare clinics, milk
depots, nursery schools, the school medical service, etc., which monitored
the community and spread tthc new hygiene. 4 The second was the relatively
new specialty of paediatrics, a direct outgrowth of clinical medicine. 5
54
An interest in diseases of children had been shown by some general

physicians from the late nineteenth century. 6 This specialist interest was
justified in the main by the apparently peculiar presentation of various
diseases in childhood. Forsyth expressed this view in his Children in health
and disease, of 1909, when he stated: 'With few exceptions the pathological
processes of youth and of maturity are alike ... clinical effects however
differ.' 7 The name given to the Society for the Study of Diseases in Children,
founded in 1901, signified the subsidiary position of the child relative to the
disease. Hutchinson, one of the first general physicians to take an interest in
diseases of childhood, confessed that had his practice been solely restricted
to children his knowledge of children's diseases would have been 'poorer
and meaner 5 8
With the child as an object of increasing concern, and the invention of the
'problem child' in the early twentieth century9 , the medical gaze shifted
towards the diseases peculiar to children rather than the unusual mani-
festation of'adult diseases' in children. The British Paediatric Association,
founded in 1928, was born of this view and by the 19405 it had become the
rule rather than the exception for physicians in the diseases of children to
confine themselves to that specialty. In effect, a mere side-interest of
general physicians became a specialty in its own right through the
elaboration of childhood and childhood relationships. Yet the focus on
childhood remained essentially a focus on a figure in the Panopticon, in that
inter-war paediatrics reproduced the cognitive and organisational forms of
its parent medical discipline. Meetings, for example, at the Section for the
Study of Diseases in Children, and research reported in Archives ofDisease in
Childhood, were all wholly concerned with the examination of the character-
istics of the individual case. 10
A major realignment in paediatrics began to occur during World War 11
when the paediatrician's gaze shifted from the child as a figure in the
Panopticon to the child in the community: children were evacuated; food
for children was in short supply and the threat of malnutrition loomed;
children were stressed by disruption of families and loss of parents. The
problem was no longer the place of the disease in its nosology but of the
child in its community and social context. As Jameson, Chief Medical
Officer at the Ministry of Health argued 'in the past paediatrics had shown
too little interest in child development and had rather confined their
attention to the sick child'. 11 The techniques of the public health child
health services ('periodical medical examination coupled with surveillance
of a less formal kind' 12 ) would now need to be learned and deployed by a
community orientated paediatrics.
During the war, paediatricians meeting at the Royal Society of Medicine
increasingly discussed the problems of the child in the community.
Discussions were held on the problems of the evacuated child, the role of
child guidance, the effects of war-time rationing on child health, nutritional
anaemia in children, the decline in breast feeding and the future of the
school medical services. 13 The child in the war-time community had to be
constantly observed, data recorded and health care organised.
Yet how were these various facets of the social life of childhood to be
made known? How could malnutrition be recognised? How could emotion-
al disturbance be identified? There were two problems. One was the
problem of the normal child, which was to dominate post-war paediatrics -
What were the normal dietary requirements? What was the normal
haemoglobin level? What was normal psychological adjustment? The
second problem was, given these critieria of normality, how were deviations
and variations in children to be picked up? The solution to both problems
was the survey.
The new perception of the child, as a figure within the social domain,
immediately brought to the attention of paediatricians the lack of data on
normal children. In a discussion of the effects of war-time rationing on
children at the Royal Society of Medicine, unpublished data from a dietary
survey of 1000 middle class children, between 1935 and 1939, were brought
to the notice of members. 14 Data from a small group of children of parents in
the professions in Newcastle, published by Newcastle Corporation Health
Department, were used in a discussion of nutritional anaemia. 15 The
shortage of good-quality published data was apparent and, during the war
years, the first moves were made to correct this deficiency.
Starting in the autumn of 1941 the haemoglobin levels of a group of
normal woman and children were collected so that, by 1942, 550 women
and 850 children had been recorded. 16 A study from Birmingham reported
that 2698 children had been breast-fed in the first quarter of 1942 compared
with 1937 in the first quarter of ig4i. 17 A nutritional survey of school
children in Oxfordshire, London and Birmingham was undertaken by the
Oxford Nutrition Survey of the Institute of Social Medicine in 1943. 18
Gradually, these observations of the social body of the child came to
supplement the examination of the individual case and paediatric know-
ledge became based, not only on clinical phenomena, but also on social
facts.
It rapidly became apparent that perhaps the greatest ignorance was of
normal growth and development. The height and weight of a child could
not be judged by the traditional clinical method of approximation to a
nosological category, for, given the apparent range of normal variability,
there were no criteria by which that category could be sustained. The only
viable referrent would be other children but this would require knowledge
of the full range of heights and weights of all normal children.
In 1942 the Executive Committee of the British Paediatric Association

established a Sub-Committee to investigate the feasibility of a height and
weight survey of the population. There was initially some difficulty in
obtaining funding: the Science Committee of the Royal College of
Physicians declined to help, as did the Nuffield Foundation. In 1949 a new
Committee was established to conduct a survey of growth in children, this
time in cooperation with the Ministries of Health and Education. 19
In thf meantime, other studies were carried out. Observations on the
growth of children were reported from the Institute of Social Medicine at
Oxford. 20 A study of the relation of puberty to height and weight was
published. 21 A retrospective study of the relationship of birth weight to
mental development was presented to the AGM of the British Paediatric
Association in ig48. 22 Yet, as Faulkner pointed out with some impatience
in 1952, these various studies were open to criticism and until longitudinal
findings were reported 'there was no simple satisfactory test of normal
growth in the human child';23 equally, there was no technique by which the
outline of the normal child could be fabricated.
In 1964, looking back over the growth of paediatrics, MacKeith noted
that the 'most remarkable single change in paediatric practice in the last 20
years is that today a paediatrician's routine examination nearly always
includes some estimate of the child's development'. 24 The major innova-
tions that had enabled the realisation of this procedure were the growth
curves and percentile charts derived from the findings of the post-war
longitudinal studies. 25 Whereas pre-war paediatrics had viewed the child
as a solitary figure in the Panopticon, to be observed, described and
analysed, post-war paediatrics, through the technology of the survey,
placed the child against the background of the social body - essentially to be
compared. The sick body of the child was no longer to be constructed by a
clinical gaze which sought to analyse in the context of nosological
referrents, but by a gaze over the normal child against whom, by
juxtaposition, the sick child was created.
The discovery of the normal child as the context for paediatric
judgements posed an immediate problem, however. A test of normal
growth assumed the possibility of abnormal growth: yet, how, from
knowledge of other childrens' growth, could the boundaries of normality be
identified? When was a single point on the growth and weight chart, to
which the sick child was reduced, to be construed as abnormal? The
questions seemed important yet they could not be answered from the
percentile chart. The problem was that the questions themselves belonged
to an alternative paradigm, a perceptual gaze which sub-divided the world
of childhood into normal and abnormal. An inherent characteristic of the
survey and of the Dispensary was that it distributed variables
continuously within the social domain and, while it was possible to declare
one child 'shorter than average' or 'only in the second percentile', it was
obviously entirely arbitrary to declare such a rinding abnormal.
Thus, in the immediate post-war period, while those paediatricians who
functioned in a Dispensary apparatus demanded the technologies and
findings of the survey, those who maintained a more limited view of the
child's body found the survey confused matters rather than clarified them.
Bransby of the Ministry of Health had opposed the British Paediatric
Association's proposed war-time survey of height and weight on the
grounds that it would serve 'no useful purpose as no conclusions could be
drawn from it'. 26 Later, in 1950, he still insisted that the boundaries of
abnormality should be imposed on the survey: it is 'not sufficient simply to
set statistical limits to normality; a standard must stand up to clinical
test'.27 Yet how could a clinical gaze, which examined the state of the
individual child, be consonant with a perception which reduced the child to
a point or line on the growth and weight chart? The child as located on the
chart, in its social context, necessitated a 'naked-eye judgement' which
explicitly accepted that the 'definition of abnormality must be "arbi-
trary"'.28 While the survey had seemed to promise the identification and
recognition of abnormality in the community, its actual effect had been to
confound it. Douglas, reporting on his national longitudinal study started
in 1948, pointed out that his findings about the heights and weights of
two-year-olds were of no value in isolating 'those who have suffered from
ill-health, poor home conditions, or inefficient maternal care', nor was it
possible to be predictive from them.29
Thus the survey began to weaken the boundary between normality and
abnormality in childhood. It seemed to the paediatrician that this posed
problems for the identification of the abnormal child; the corollary was that
normality became essentially problematic. In effect, the survey which
sought to map the social body had identified its own set of problems which
further justified its extension. The result was twofold: an increasing reliance
on the survey as an instrument of research in paediatrics and a new
discourse on the normal child.
Problems of the normal child

In 1953 Illingworth published the first edition of his classic text, The normal
child.30 He pointed out that, at that time, it could not be said that knowledge
of the normal child was an essential basis for the study of the sick and
diseased child, but that he felt there was a need to know considerable
variations of normal. By the second edition of 1957 he could note the
'increasing interest in the problems of the normal child'. 31
The 'problems of the normal child' would have been a contradiction in

terms for the Panopticon, but, for the Dispensary, all children were normal
in that they belonged to the social body: it was the problems of the social
body, as they manifested themselves through the sick child, that informed
this new medical perception. The Panopticon had constituted bodies
through examining their abnormalities, the Dispensary constituted them
through locating them in the community, in their social context, embedded
in a network of relationships. Thus, whereas the gaze of the pre-war years
had invented particular problems of the child (delicate, nervous, solitary,
neuropathic, etc.), the paediatrics of the post-war world, in focusing on
relationships of childhood, invented the series of problems which were
located in their social environment - the battered child, the deprived child,
the neglected child, the abused child. Pre-war, the child was essentially
constituted by analysis of discrete bodies and problems were located within
the child; post-war, the child was increasingly constituted by its social
mapping in the community and its problems were located around the child.
In 1964, for example, Illingworth argued that the idea of the maladjusted
child was inappropriate: 'it is the parents who are maladjusted not the
child'. 32
In the post-war world the normal child came to invest the body of the sick
child. Disease could not be identified in isolation: the normal child of three
was very different from the normal child often. 'Manifestations of one and
the same disorder may differ in patients of different age. What is abnormal
at one period of life may be normal at another. Symptoms, signs, and the
results of investigations have to be interpreted in the light of the patient's
age and maturity.... In its broad ambit paediatrics must necessarily
include such diverse aspects of growth as the biochemical and immunolo-
gical, the intellectual, emotional and social.'33
The normal child, as constituted by the investigation of growth and
development, pervaded the diseased child. On the one hand, within the
diseased child, 'the natural inherent struggle to maintain or regain growth
can be seen to have its influence on the disease process itself'.34 It remained
for the paediatrician 'to decide whether the derangement from the average
is of quantitative importance. Why is the boy below average height, and
should he be given testosterone? Is the factor in this girl's obesity
constitutional, endocrine or emotional, and should a carbohydrate-
restricted diet be imposed upon her? Is this child's failure to gain weight
due to infection, fatigue or emotion, and how may it be corrected?' 35 The
break with the panoptic vision of clinico-pathological medicine was to
replace the question: 'Has this patient a disease?' with: 'Is this child
growing normally?'36
The other component of the increasing visibility of childhood was the
6o Political anatomy of the body
gaze over the mind of the developing child. Observation of the mind of the
child had arisen earlier in the century in the context of the school medical
service, the school psychological service and the emergence of child
guidance. Yet it was not until the years of World War 11 that paediatrics, at
the same time as it deployed the survey, also discovered the mind of the
child. The Executive Committee of the British Paediatric Association had,
in 1943, suggested a close alliance between child guidance clinics and
childrens' hospitals when the dangers to children of the war-time
situation had risen to such salience. 37 A special Child Psychology Sub-
Committce was created in 1944 to examine this area of paediatric practice:
it reported in 1946. The Committee argued that paediatricians should show
a deeper interest in child psychology because 'it is false to attempt to draw a
hard and fast line between physical and psychological disabilities'
Moreover, 'without a study of both the normal and abnormal child, adult
neuroses and psychoses cannot be understood'. 38 In 1948 the Child
Psychology Sub-Committee pressed for psychiatric departments in all
childrens' hospitals. 39
Thus, in 1953, when Illingworth published the first edition of The normal
child, he was concerned with describing both physical and psychological
normality. For the latter he drew on some American work from the
inter-war years carried out by Gesell. 40 Gesell had started charting the
behaviour development of normal children from birth to six years old, in
1919, at the Yale Clinic of Child Development (founded in 1911) . 41 From
this work Gesell created a developmental schedule of 150 items. In 1927 he
started on a larger and more comprehensive survey of behaviour develop-
ment: a relatively homogeneous group of 107 infants were observed, some
repeatedly, at 15 age levels from 4 to 56 weeks. In his Biographies of child
development, of 1939, Gesell extended the growth data on childhood into
school life. 42
For his studies Gesell constructed an observation dome in which the
child was placed, while the researchers stood behind a one-way screen. In
this 'intimacy of observation with detachment', Gesell, in effect, had
devised a structure which followed the principles and architectural outlines
of the Panopticon, the chief exception being that the geographical position
of observers and observed were reversed. 43 In his writings, too, Gesell
implicitly endorsed the mechanisms of surveillance and their disciplinary
effects as found in the Panopticon. He predicted, for example, in 1923, that
the 'developmental hygiene of the pre-school child will gradually be
brought under systematic social control',44 And he pointed out in 1939 that
too much attention was paid to 'mere training and instruction. Our central
task, particularly in the first five years of life, is to discover and to respect
individuality.' 45
In 1965. reflecting on the history of paediatrics, the President of the

British Paediatric Association thought it 'fortunate' that 'parallel with
paediatric enlightenment ... psychiatry matured'.46 Fortunate or not, the
enlightenment of paediatrics and maturation of psychiatry were both
components of the same underlying vision. In post-war paediatrics, the
continuous sweep of the survey was united with the observation of
childrens' minds. The result was a new paediatrician: the 'new thing was
the importance attached to growth, development and adjustment during
infancy and childhood. Development was not only physical but also
intellectual and social so that behaviour within the family, the school and
society had to be included in the wide sweep of his horizons.'47 If the
post-war period 'might be termed the age of the mass survey',48 it was also
the age of the continuous gaze over the normal.
The paediatric principle

In the post-war world, paediatrics was a new discipline with a new vision. It
was no longer- as it had been before the war- a specialism: 'paediatrics is
in fact general medicine during a particular age period'. 49 A specialist
emphasised only one part of a whole whereas paediatrics was concerned
with 'the general study of children in health and disease - and is not limited
by one aspect of disease or disease of one organ'. 50 Similarly, it was held that
children's hospitals were not special hospitals to be classed with urological,
ophthalmic, dental and mental hospitals: indeed, it was claimed that
children's hospitals were more 'general' than the so-called general
hospitals, some of which excluded diseases like pulmonary tuberculosis.51
The increasing concern with children 'in health and disease' represented
a growing tension between the new discipline and its parent. Until the early
years of the national health service, paediatric teaching had begun 'with the
assumption that the child is but a miniature version of the adult ... his
diseases were the same as in adults but less severe ... his psychological
make-up was similar to that of the adult but more innocent... and that his
treatment is identical except that it is scaled down to size'. 52 But, as Apley
pointed out a decade or so later, paediatrics was not solely 'diseases of
children or medicine in miniature but was a discipline with not only a
philosophy but an identity of its own. Childhood can be neither understood
nor taught simply by extrapolating back from adults.' 53
Even as late as 1971, as Mitchell argued, it was 'still sometimes necessary
to spell out the different needs of children and adults to specialists in
technological medicine who cannot see beyond the organ of their interest'. 54
For example, it was claimed that whereas admission to hospital was usually
relatively incidental for the adult, for the child 'it is an experience occurring
during a critical period of growth which may leave a lasting mark on his
personality'. 55 Thus the British Paediatric Association asserted that the
failure to segregate children in accident and emergency departments was
not in accord with the generally accepted Report on the Welfare of Children
in Hospital, and the Association had also to remind members of the Faculty
of Ophthalmologists that their policy of seeing children in ophthalmology
departments contravened the Report's recommendations.56
If the particular needs of children demanded separate hospitals, they also
warranted specialist personnel. The principle of having children in hospital
cared for by sick-child nurses was firmly established, the BPA having
successfully resisted an attempt by the General Nursing Council to abolish
the sick-child nurse register in the early sixties. 57 But 'paediatric' skills were
not only needed by nurses; even 'medical technicians and auxiliary
workers, who increasingly come into contact with children in hospital, often
have no special paediatric training and may be clumsy and inexpert'. 58
The Report of the Committee on Child Health Services in 1976 (The
Court Report) 59 carried the 'paediatric principle' further. It recommended
special child-health visitors, general practitioner paediatricians and
paediatric experts in various fields of medicine. The Report reaffirmed the
view of the BPA60 that there was a need for paediatric neurologists,
cardiologists, nephrologists, endocrinologists, gastro-enterologists, haema-
tologists, and oncologists. Allied specialties included paediatric surgeons,
anaesthetists, radiologists, orthopaedic surgeons, ear, nose and throat
surgeons, ophthalmologists, dermatologists, medical geneticists, morbid
anatomists, histo-pathologists, chemical pathologists, and micro-
biologists. 'Since paediatric specialists work and share facilities with adult
specialists in the same discipline, why are they necessary? The answer is
that the needs which justified the separation of paediatrics from adult
medicine apply here with equal force.'61
Thus 'the childrens' physician metamorphosed into a paediatrician,
moved away from his specialisation in organic disease in the age group of
birth to puberty, as he realised the importance of development during
childhood and infancy'.62 Growth and development became 'the quintes-
sence of modern paediatrics'63 and developmental paediatrics the 'founda-
tion' of the discipline. 64 A trend was instituted 'away from pure paediatrics,
with its traditional emphasis on diagnosis and treatment of acute medical
problems, towards developmental paediatrics'.65 Capon expressed the
prevailing mood in 1950: the various methods of clinical examination, the
bulwark of clinical medicine, were 'techniques towards this end ... [but]
they must be regarded as preliminaries'. 66
In extending the survey to the community, paediatrics had invented the
normal child. Yet, paradoxically, as Illingworth observed in the preface of
his book, 'it is almost impossible to define the normal'.67 Although the
individual child was plotted on a growth and development curve, the
implications were somewhat vague: the average was not the normal, those
outside the range not necessarily abnormal and maximum growth was not
necessarily optimal. 68 Nevertheless, this system of 'non-evaluative' map-
ping continued and, moreover, became the cornerstone of the new
paediatrics. Every child was normal and, at the same time, 'all normal
children have behaviour problems'. 69 Notions of normality and abnormal-
ity, problems and non-problems lost their discriminatory value. Know-
ledge of the child became expressed as a single and individual growth
trajectory constructed by joining the points marked on a percentile growth
chart. Diagnosis and the medical problem, as elements of the Panopticon,
were replaced by a constant normalising gaze exercised by a new medical
discipline over the growth and development of all children.
7
Disciplines of the survey: 2. psychiatry
In 1924, Newman, the Chief Medical Officer of the Board of Education -

and an early exponent of the 'new hygiene' - appointed a Mental Deficiency
Committee drawn from the Board of Education and the Board of Control to
advise on the problems presented by the mentally defective. 1 The
Committee represented the culmination of a series of government moves to
identify and provide for mentally defective children.
The Mental Deficiency Act of 1913 had laid upon local education
authorities the duty of discovering all the mentally defective children in
their areas between the ages of seven and sixteen, and the duty of providing
special education for these children was laid down in the Elementary
Education (Defective and Epileptic Children) Act of 1914. The local
education authority returns on the numbers of mental defectives, however,
were extremely variable. Prevalence seemed to vary from 0.73 per 1000
children in one area to 16.14 per 1000 children in another. In the words of
the Mental Deficiency Committee: 'It is obvious that no sound administra-
tion could be built on such figures, and that little progress could be made
until the number of mentally defective children who were likely to be found
in any area could be known with reasonable accuracy.'2 Hence the Mental
Deficiency Committee was charged with answering two questions - How
many mentally defective children are there? And what is the best thing to do
with them?
One of the first decisions of the Committee was that their investigation
should not be constrained to children falling within the province of the
Board of Education 'but must extend to children of all grades of mental
defect.... Any solution of the problem of dealing with one category
depended upon, and at the same time affected, the solution of that of
dealing with the other category.'3 The field of enquiry was further extended
by taking into consideration mentally defective adults because local mental
deficiency authorities also were found to have problems in establishing
accurate numbers for those within their jurisdiction.
The Committee decided that the only means of accurately ascertaining
the number of mental defectives in the community was by 'intensive
64
Disciplines of the survey: 2. psychiatry 65
investigations in a number of areas'.4 Six areas were chosen of such varied

social and geographical characteristics as to be representative of the
country. The particular details of the investigation were handed over to Dr
E.O. Lewis who carried out a community survey between 1925 and 1927. 5
Within each area, the mentally defective, and those on the borderline, were
identified by a variety of means. School teachers were asked to provide
names of those either defective or borderline; those too young to attend
school were visited in their own homes, their identities being given by local
mental deficiency committees, officers of child welfare clinics, health
visitors and district nurses; adult mental defectives were similarly identified
by the various institutions, organisations and personnel that worked in and
knew the community.
From early in the century when legislation established Dispensary-like
mechanisms to monitor the numbers of locations of mental defectives, the
local mental deficiency authorities had tried to build up an apparatus of
surveillance. 6 It had, however, proved insufficient, and it seemed that many
defectives were missed and identification criteria were variable. Lewis's
report to the Mental Deficiency Committee was an attempt to remedy these
inadequacies. Through a wider network of key community workers, he
sought to identify the unknown defective and, by using standardised tests,
to make figures from different areas directly comparable. Within this study
can be discerned the rudiments of the survey: an apparatus of surveillance
to encompass all the community; the community workers (later the survey
itself) at the point at which data was gathered; sampling techniques, here
used to identify geographical areas for investigation (later used to identify
respondents); and standardised criteria by which to discriminate between
the normal and abnormal. While Lewis's survey did not attempt to map the
normal - as later surveys would - he did examine 'borderline' cases. In
particular, he requested teachers, when providing names of the mentally
retarded, to list 15% of the most retarded children in each age group so that
it was 'almost certain that any child who was really mentally defective
appeared in the lists of names of this group'. 7 The true defectives were then
identified by group tests and medical examination.
Writing some years later, in 1943, Lemkau and his colleagues, in an
international review of statistical studies on the prevalence and incidence of
mental disorder in sample populations carried out anywhere in the world,
pointed to Lewis's study as a 'model' which no study had emulated. In the
meantime there had been other investigations, but these, it was felt, were all
flawed in their selection of a sample population. 8
In Britain in 1934, Slater had published a survey into the incidence of
mental disorder because he felt it 'important to form some estimate of
mental disorder as a whole' for which there were 'no figures available in
England'.9 His estimate, however, was based entirely on admission figures
from the Board of Control and made no attempt to establish unrecognised
morbidity. Slater also published another study (with a similar bias), in
1943, based on admissions to a war-time emergency hospital between 1939
and 1941. 10
One of the earliest attempts to improve on Lewis's study and estimate the
mental health of a total population was the 'mental health survey of a rural
area', by Mayer-Gross, published in ig48. n The problem, as Mayer-Gross
observed, was that surveys in the past had tended only to deal with
distinctly abnormal populations. This might have been methodologically
advantageous but 'during the last 30 years the interert of psychiatry has
shifted from the major psychoses, statistically relatively rare occurrences,
to the milder and borderline cases, the minor deviations from the normal
average'. 12 It was this new morbidity, more frequent, perhaps more
important, of which psychiatry required more knowledge.
The gaze to the 'milder', the 'borderline' and the 'minor deviations' were
characteristics of an extended disciplinary apparatus. Mental abnormality
began to be seen as not specifically localisable to one person but as a
phenomenon which appeared and reappeared in the context of a dynamic
and changing 'normal variability'. The new psychiatric gaze was therefore
not so much concerned with the examination and celebration of the
individual case but with the ever-changing limits of normal variability
within the community. Hence the importance of survey techniques which
enabled the normal community to be known.
But how was the survey to be adapted for identifying mental disorder?
Mayer-Gross was aware of the advantages of surveying everyone within his
defined population, but finally decided against it on the grounds that the
'unavoidable publicity would have led to deliberate withholding of cases
and facts'. 13 In consequence, he used a modified version of Lewis's
technique, starting from local hospital discharges supplemented with
information from community workers. Yet there had already been a
rigorous community survey of mental health which had encountered little
resistance or non-cooperation from respondents: that survey was the
government's War-time Social Survey. Glover, the eminent psychoanalyst,
hailed the Survey as the beginning of a new social psychiatry. Under the
guise of monitoring public opinion, the Survey provided a means of
observing national mental health and was therefore 'a ringing blow struck
for psychological medicine' 14
Glover pointed out that the Social Survey provided 'a comparatively
exact instrument for the expression of democratic feeling [and] that it
permits the rapid uncovering of avoidable sources of friction ... without
denying the social or political significance of public opinion, the Ministry of
Information has established that group feeling is a medico-psychological

concern and that it calls for instruments of precision in diagnosis'. 15
Normalisation of the psychiatric patient

The psychiatric morbidity survey, which was deployed during the war and
with increasing frequency in the post-war world, was but one facet of the
changing perception of the mentally ill, which, like the similar changes in
other areas of medicine, represented a further extension of a disciplinary
gaze. In essence, the post-war psychiatric perception was a normalising
gaze: not, as in the Panopticon, a normalising gaze over an enclosed and
inherently 'abnormal' population, but over an entire domain. This
normalising gaze over the whole tended to obliterate the legitimacy of the
distinction between normal and abnormal and tended to create one
community where before there had been two.
Before and immediately after World War n, two modalities of power can
be discerned: on the one hand, the old techniques of confinement,
separation and exile of the insane; on the other, the growing strength of a
community gaze. The treatment regimens that developed tended to reflect
these mechanisms of power. The old principle, that terror and shock were
good for the insane (in that it might bridge the gap between the divided
communities of sanity and madness), was redeployed in various, though
'humanitarian', forms. The 'emotional shock' of the 19203, 16 gave way to
the shock of insulin coma, the convulsions produced by cardiazol and
electro-shock treatment and psychosurgery of the ig3os. 17 En route,
thyroidectomy, prolonged narcosis, the production of aseptic meningitis,
leucocytosis, controllable fever and high frequency currents were among
treatments that had their moments of fashion. 18
By the 19505, chemotherapy, earlier discharge and lower rates of
hospitalisation had become more common - a process Scull refers to as
'decarceration'. 19 The principle of the 'unlocked door'20, whereby the old
asylum was opened up, was a corollary of a gaze which saw no distinction
between healthy and ill, sane and mad. The open door enabled the high
walls of the asylum to be pierced: it established the conditions for the
emergence of psychiatric day hospitals, 21 regular visiting22 and treatment
regimes which emphasised discharge. Mental institutions could become
'hospitals instead of asylums', emphasis could be placed on 'the clinical
needs of the patient and not on his segregation' and fresh terminology could
be employed 'free of unhappy associations'.23
At the same time as post-war psychiatric policies attempted to end the
exclusion of the mentally ill from the community, the boundaries between
psychiatric diagnostic categories were challenged. Were the neuroses and
psychoses conceptually exclusive? And was the difference between the
neuroses and 'normality' qualitative? Inter-war psychiatry had been
largely divided into those who managed the neuroses in the community -
the special clinics, out-patients, the GP surgery - and those who guarded
over the psychoses within the mental hospital. The post-war world saw a
unified psychiatry which dealt with both neuroses and psychoses: the old
hospital psychiatry 'absorbed not only the principles of psychotherapy but
also its practitioners' 24
At the same time, psychiatry took over from the neurologists the little
that the latter continued to claim of the neuroses. Walshe had grudgingly
accepted a chapter on psychoneurosis in his Diseases of the nervous system, of
1940, but, by the fifth edition of 1947, their inclusion was only justified to
the extent that they had to be separated from neurological problems in the
diagnosis. In the eighth edition, of 1955, the chapter had been rewritten and
restricted itself solely to 'problems the neurologists alone can usefully
undertake'.25 Brain's Diseases of the nervous system, first published in 1933, at
first reflected Brain's belief that mind and brain should be kept together;26
but, in 1951, neurasthenia was dropped and anxiety neurosis followed suit
in ig&2.27 In effect, the attempt during the war to create a unified
neuro-psychiatry28 had failed.
Whereas before the war, separation into those who treated psychoses and
those who treated neuroses had been usual, after the war, the assumption
was that they were united and the 'constant danger' was that they might be
sub-divided.29 Similarly, the cognitive and clinical separation of the
psychoses from the neuroses appeared to be increasingly problematic. In
1965 Merskey & Tonge in their text, Psychiatric illness, suggested it was
difficult to distinguish between psychoses and neuroses.30 In 1970 Howells
proposed a new psychiatric nosology which would integrate the psychoses
and the neuroses. 31 Crown, in his Essential principles of psychiatry, of 1970,
suggested that all psychiatric phenomena were quantitative and not
qualitative deviations from normal.32 On the other hand, Hamilton argued
in Clinicalpsychopathology, of 1974, that the psychoses were 'true illnesses in
which a sharp break in the personality occurs'.33 Trethowan perhaps
best summed up the mood in his Psychiatry, of 1979, when he claimed that
the question of how far psychoses differ qualitatively from abnormal
emotional reactions 'still remains one of psychiatry's fundamental
problems'.34
The Memorandum on the Future Organisation of Psychiatric Services,
in 1945, had commented that 'where psychiatry begins and ends has not
been settled'. 35 The boundary between the normal population and the
neuroses was ill defined. 'The psychological disorders in these conditions
are mainly quantitative exaggerations of normal psychological features, so
it is often difficult to decide where normality ends and abnormality
begins.' Indeed, it was possible to argue that these mental problems were
'not illnesses in the usual sense of the word'. 36
This blurring of the distinction between the normal and the abnormal
was considerably aided by the findings of the new surveys (which were
themselves, of course, part of the new perception). Results from the large
American community studies of psychiatric morbidity, commenced
immediately after the war, were being published and they recorded
extremely high prevalence rates for the neuroses. 37 Studies by Primrose,
and later by Brown, confirmed the wide distribution of psychiatric
morbidity. 38 Various surveys of morbidity within the community or within
general practice consultations offered further support39 and the writings of
Michael Balint led to the intrusion of a 'psychiatric' perspective into all
consultations. 40
It was found, for example, that between 30 and 90% of the 'organic'
complaints under the care of general clinicians had a psychiatric
component. 41 Psychiatry could therefore intrude into the very practice of
medicine itself, observing, checking, correcting, monitoring. 'The nature of
our speciality makes us especially conscious of the psychological and social
problems caused by illness.'42 Psychiatrists would, of necessity, have to
teach human relations or those psychological processes which were vital for
the practice of medicine. 43 The importance of this claim had been presented
to the House of Commons in the call for a Royal Commission on Medical
Education in ig6i 44 and the report of the Commission in 1968 had
commended this perspective and stressed the role of psychiatry in
understanding the very essence of practice and the fullest comprehension of
patient problems.45
From the first edition of their book, A textbook of psychiatry, in 1927,
Henderson & Gillespie had included a brief historical review of the subject
which ended with the ' Hospital period'. In 1944, in recognition of the new
domain of psychiatry, they added a section on the 'Social or community
period' Here they recommended the extension of psychiatry into the
community: in the education of those in charge of nurseries, residential
schools, and hostels, in the selection and education of youth leaders and
into industry and the field of sickness absence. 'It seems best that
psychiatry should extend to the community in these ways, where the
ground is already explored and known, before it tries to extend still further
and become part of community life, of government and even of inter-
national relations.' 46
The fabrication of subjects

In 1911, in his book Unsoundness of mind, Clouston pointed out that
neurasthenia was sometimes seen among highly educated young women,
•jo Political anatomy of the body
though it was uncommon among healthily reared young country women.

From this he concluded that 'if men and women live as they should do
[neurasthenia] would scarcely exist at all'.47 In 1937, Ross, in his The
common neuroses, claimed that the neuroses were caused by a faulty response
to life's difficulties. 48
These two diagnoses differed considerably in form from insanity. The
insane were exiled for being mad in a community of sanity; the effect of this
policy of exclusion was to reaffirm the rationality of the 'normal'
community. Neurasthenia and, more important, the later neuroses,
operated by a different mechanism. In these cases the identification of the
disorder had positive effects: the patients could change and be made well,
and appropriate life styles and relationships could be indicated to the
general population. Thus, whereas madness had reaffirmed through
negative action (exclusion), the neuroses both reaffirmed and effected
change through positive action (surveillance). The invention of the
neuroses, therefore, constituted a lighter more subtle discipline and, at
the same time, one with multiple effects: where madness had merely
reaffirmed, by comparison, one aspect of mental functioning, the neuroses
could potentially create its multi-dimensional totality.
Panoptic power had fabricated bodies by making them the objects of an
observing eye. The new regime exercised surveillance over the whole
population and, because it observed the mind of everyone, was in a better
position to make the individual a point of articulation for power: both an
effect of power and a point from which power was exercised. Where the
Panopticon had created individuals as objects the extended community gaze
established an analysable social space, around and between these same
bodies, which came to be seen as one of their essential characteristics. In
other words, the gaze began to fabricate a subjective space around the
object of the body. Such a change in the effects of the psychiatric gaze is in
evidence from late in the inter-war period when the psychiatric patient
made an appearance as a part of the treatment regime instead of its object.
The mental hospital began to change from a place of exile to a point of
rehabilitation. From a regime which repressed and negated, by the
bluntness of its powers of exclusion and containment, emerged a disci-
plinary machine which segmented and ordered hierarchically so that the
mentally ill might become part of the machinery of power rather than a
victim of it. The mental hospital was not simply an institution of exclusion;
instead, its characteristics, its structures, its darkest, remotest parts could
be analysed, rcspatialised and integrated to create a total environment, a
subtle disciplinary machine.
The patient was no longer the object of the hospital but the subject of its
essence. The patient was no longer a member of the community of the
insane but an individual with 'a biography, a social setting, a constitution,
with experiences undergone and effects rendered, a life with purpose and
with handicaps'. Treatment, 'like the illnesses themselves must be viewed
as a whole scheme or pattern of activity': it 'starts from the moment of
introduction to the patient'. 49 Thereafter, the social organisation of the
hospital could provide a total therapeutic regime. Improved communica-
tion enabled problems of meaning, of handling knowledge, of reaching
consensus on goals, etc., to be debated and analysed throughout the
hospital hicrafchy (and ultimately to lead to the demise of the latter). 50 The
integration of administration and therapy could, in effect, make adminis-
trative action which for so long had acted as an impediment a therapy in
its own right. 51 The vision emerged of a therapeutic community which
would act on the patient in a multiplicity of ways.
With this view of the hospital as a therapy in itself (not merely a place of
therapy), its various effects could be analysed. Its internal arrangements
were increasingly reorganised to generate the sort of environment which
would enable the patient to be returned to the community. 52 Yet the
hospital with a power for positive effect could also be construed, with
inappropriate organisation, as a power for negative effect. Might not the
hospital be creating some of the problems it was meant to be treating? A
new analysis of space, routine and organisation emerged in the 19505,
which stressed the negative effects of the hospital. A new discourse on
labelling, stigma and institutionalisation arose both in medicine and in the
related social sciences: 53 a discourse which opposed the depersonalising
aspects of institutional life (which had been one of the chief mechanisms of
the Panopticon) and replaced it with notions of personal identity and
subjectivity.
The importance accorded patient meaning and subjectivity within the
new mechanisms of power meant that, at the very moment of its triumph,
psychiatry had to discard the external referrcnts by which patients had
previously been judged and objectified. The problem with the promotion of
mental health, Sir Aubrey Lewis observed in 1958, was that it had 'no
operational referrcnts' and it could only be expressed in terms 'undefined
and undcfinablc'.54 Psychiatry had to proceed with caution. MacCalman,
as early as 1949, advised his colleagues to 'resist the implied flattery of being
consulted about ever wider social and national problems'. 55 As Curran
argued in his Presidential Address to the Section of Psychiatry of the Royal
Society of Medicine a few years later, psychiatry had to resist expansionist
claims. 56
This position was mirrored in the human sciences, which, from the same
period onwards, developed an 'anti-psychiatry' whose main focus of attack
was the apparently arbitrary referrcnts by which psychiatrists judged their
patients. 57 Yet even as these critics decried the visible excess of a psychiatry
with 'objective' referrcnts, changes in the form and mechanism of the
psychiatric gaze were already under way to make its operation more
invisible and more pervasive.
The relationship between psychiatrist and patient began to be recon-
strucd. The disciplinary gaze, which sought to encompass the totality of the
patient, in a sclf-reflcxivc gesture, also turned to examine the psychiatrist.
Besides listening to and observing the patient, the doctor had to be
self-aware: 58 'What is my attitude? Am I understanding the situation from
the patient's point of view, or from mine alone? What is my reaction to his
behaviour?' 5y In short, the interview had to examine both the patient's and
the psychiatrist's words and actions. 'Thus in an interview there arc at least
two persons to be heard and two to be observed both as individuals and in
terms of their interaction.'60 Both psychiatrists and patients were subjects.
The diagnosis, as classically understood, began to disappear. For some,
it was replaced by the 'formulation - a construction of working hypotheses
of the nature of the patient's problem' 61 - for others, a 'multi-dimensional
diagnosis' 62 In effect, these new diagnostic conventions represented an
attempt to summarise what was individual about the patient. Thus
psychiatry moved from classification to individual description: 'the most
essential feature in the recent development of psychiatry has been that the
diagnosis of disease has given place to absorption in the personal tragedy of
individuals'. 63 It was probably no coincidence that a phenomenological
influence spread through psychiatry in the igSos.64
Under the old regime the psychiatric judgement of normality or
abnormality had been a function of external criteria; now the patient began
to become his or her own judge and referrent. Ts the present state foreign to
the patient's previous personality?' was the first question to be posed.65 Or,
put another way, 'the most important comparison is probably that between
the present state and the previous personality'.66 A technology of'coping'
was theoretically refined and a vast literature on 'stress' emerged in the
post-war years. Patients would define their own limits and make their own
decisions: 'when a patient calls on his doctor for help he generally implies
that his own efforts are not enough'.67
A psychiatry based on the external referrent of the psychiatrist objec-
tified the patient: a psychiatry which defined the patient as a subject, which
explored and valued subjectivity, signified a new power. When the
psychiatrist could freely enter the mind of the patient, when the patient
internalised the criteria of normality and became his own judge, then the
power of the new surveillance could move with greater speed, but above all
with invisibility. A liberated and humane psychiatry, together with the
concerned human sciences, could be crystallised around an efficient and
pervasive gaze which analysed and fabricated the mind of the subject.
8
3. general practice
The changes in medicine which occurred at the end of the eighteenth

century ushered in a new 'regime of truth' in which the deepest secrets of the
human body could only be revealed by a detailed examination and
analysis. 1 Consequently, the history of medicine from that period is also the
history of a reductionist gaze to the body of the patient, characterised by a
growth in the number of hospitals, the invention of more investigative
procedures, and the emergence of a specialised division of labour within the
medical profession which enabled the clinical gaze to become more
detailed.
The process of investigating and examining bodies grew significantly in
the twentieth century. First, there was a rapid growth in the number of
hospital beds: between 1911 and 1938, for example, the number of beds in
voluntary hospitals doubled. 2 By 1929, when the Local Government Act
placed the old Poor Law hospitals under local authority control, the Lancet
claimed that 'the centre of gravity of medicine [has] shifted from the home
to the hospital and clinic' and this would have 'the effect of popularising
hospitals still further'. 3
Second, the process of diagnosis within hospitals, the 'gaze' which
delineated the outline of the body of the patient, was considerably enhanced
by the emergence of complex laboratory-based investigations. Such was the
growth of these new diagnostic facilities in the inter-war years that a new
specialty of clinical pathology (which was later to sub-divide further into
morbid anatomy, clinical chemistry, haematology and bacteriology)
emerged. 4
The growth of hospitals to enclose bodies and the development of
laboratory tests to analyse them was accompanied by further specialisation
as different parts of the body were separately investigated. Specialisation
as a reflection of the 'natural' structure of the body of the patient-was itself
seen as an inherently 'natural' process: 'With the growth of knowledge and
the development of technique the mastery of all medicine by one man
became impossible and division of labour naturally followed.' 5
One effect of the strengthening of the panoptic vision in the inter-war
73
years was the undermining of general practice. True, the GP was employed
in the examination and investigation of individual bodies but the hospital
setting, with its accompanying resources, produced a more efficient and
powerful gaze. The GP might have been trained in a panoptic structure (the
hospital) and be cognisant with the analytic principles of the panoptic
vision, but the conditions of general practice - particularly a widely
dispersed patient population - ensured that the gaze was less effective, less
penetrating, when compared with hospital practice.
The growth in numbers of hospital beds did little therefore to help
general practice - indeed, at times, the GP was specifically excluded. Lord
Moynihan, the eminent surgeon, advised against putting local GPs on the
staffs of the new municipal hospitals unless they had 'proper credentials'.6
The advent of the national health service in 1948 further promoted this
separation by forcing doctors to choose between a hospital career or one in
general practice. The NHS, claimed the British Medical Journal with some
exaggeration, created divisions where none had existed before.7
Access to the new laboratory-based diagnostic techniques remained
under the control of hospital specialists; and GPs, until the 19505 and
19605, were not allowed to use them. The GP was therefore seen to be in
different circumstances from the hospital specialist 'who can try out a new
remedy extensively and have controls' and who had access to the laboratory
as 'a final court of appeal'.8 The growth of specialisation further under-
mined the status of the GP. 'Early specialisation is forced upon us by the
growth of knowledge and the limit of human life.'9 GPs were, of necessity,
excluded from this process as it was impossible for 'any but exceptional men
to keep an up-to-date knowledge of more than a few of the special branches
of medicine'. 10 Indeed, it was suggested in 1926 that general practice might
disappear altogether under the weight of specialisms. 11
By 1938 the British Medical Journal was aware that an atmosphere
'unfavourable and detrimental to the status of general practice created in
medical schools was not a new thing' and, indeed, in the same year the
President of the BMA pointed out that 'there is a tendency for this branch of
the profession to sink lower and lower in the estimation both of the public
and of the student body from which the profession itself is recruited'. 12 A
correspondent of the British Medical Journal objected to the GP being
described as the backbone of the profession, as it suggested the absence of a
brain. 13
Yet, at the same time as the status of general practice was so much in
decline, an alternative vision of clinical practice was coming into focus. It
began to be realised that only in general practice could the temporal
elements of illness be plotted. 'It is only the family doctor who can follow the
history of individuals during 30 or 40 years, summing up the hereditary and
Disciplines of the survey: 3. general practice 75
prenatal influences, the effects of wrong habits in childhood, the final

results of infantile and youthful ailments and the first causes of premature
decay or death.' 14 The GP was, moreover, in a position to superimpose on
this temporal dimension of the natural history of illness - its regressions,
disappearances, appearances and exacerbations - the grid formed by the
intimacies of social relationships.
In the inter-war years these two strands of an emergent community gaze
were realised in the now classic work of MacKcnzic in Scotland and Pickles
in Wcnslcydalc. From his general practice in Aberdeen, Mackenzie made
meticulous studies of'ordinary' diseases and their changes over time. 15 In
Wcnslcydalc, Pickles added to this by recording, over a number of years,
the location, distribution, spread and timing of various epidemic diseases,
particularly in the context of his patients' relationships and interactions:
the result was a social mapping of his general practice community. 16 For
example, he was able to plot the various contacts, casual and intimate, of a
young girl with hepatitis who, despite Pickles's advice, had left her sick-bed
and visited a local fair. 17
While MacKenzie and Pickles were busy constructing the analytical
lines which would enable the social body to be mapped and defined, other
GPs concentrated on the details and intimacies of the patient's social
localisation. Throughout the inter-war years, Brackenbury, the Secretary
of the BMA, advocated a 'social worker' role for the GP. 18 Many GPs
expressed interest in the newly emerging psychotherapeutic skills and
reported using them with their patients. 19 Lindsay, the President of the
British Medical Association, in 1938 argued that a role in mental hygiene
might stop the declining status of the GP. It was the GPs who could 'lead
the attack' on the large amounts of major and minor functional nervous
disease in the community and for this role they would require instruction in
the principles of medical psychology. 20 It was this perspective that the
British MedicalJournal endorsed when it suggested, in 1938, that the future of
general practice was in the 'early recognition of disease states, the
application in ordinary cases of those psychotherapeutic methods which
are becoming more and more a national need, the proper coordination of
extending specialist services, and the more effective education of the public
in medical and health matters'. 21
Surveys of sickness
The Peckham health centre had ensured that the morbidity within its
population was measured during the 19305 and the Government Survey of
Sickness, from 1944, as part of the War-time Social Survey, had kept a
constant check on the amount of illness in the community. The results of the
latter were summarised by Stocks in Sickness in the population of England and

Wales: 1944-47, published in ig4g.22
After the war further surveys of morbidity were carried out. In 1949
Pemberton recorded the age, sex and diagnosis of all people consulting
eight general practices in Sheffield during one week in winter and a week in
summer.23 McGregor carried out a similar survey of his own practice in
Scotland, in ig5O24 and Fry published his analysis of a year's morbidity in
his practice in south-east London, in iQ^2.25 Prior to these surveys, GPs
had not measured morbidity in the communities they served. Was it mere
coincidence that a group of GPs, after the war, thought it important to
measure and publish their findings on community morbidity at the same
time as the survey was mapping other areas of the social body? Or was it
that, prior to these surveys, the GP could not measure community
morbidity because it had not been conceptualised as such?
In his book, The structure of scientific revolutions, Kuhn points out that when
chemical compounds were seen as mixtures, the measurement of the
relative proportions of different elements comprising the compounds, while
technically feasible, was seen as valueless. A theory of mixtures would claim
that, on measurement, any ratio of elements might be found so there
seemed little point in identifying exact ratios from an infinite number of
possibilities. But when compounds were seen as chemical combinations of
fixed proportions of elements, the analysis of ratios of elements in a
compound became of vital importance. In short, a theory of mixtures, in its
basic assumptions, had ensured that certain measurements, though
technically feasible, were never made; a new theory with a different set of
assumptions made the same measurement of crucial significance.26
In the same way, the rapid measurement of a phenomenon in general
practice, which until then had remained unmeasured, suggests a shift of
perspective. Prior to the survey, morbidity existed in patients who were
analysed and treated individually and while the addition of these individual
cases was possible it served little purpose. The survey, on the other hand,
established a perception of the community as something inherently
measurable and calculable: the survey was part of a new 'regime of truth'
which, in its focus on the social rather than the individual body, introduced
a new direction and imperative in medical investigation.
The surveyors themselves partly justified their studies on the needs of
future planning in the NHS (itself a structure which embraced the
community), but principally on the need to know something of the nature of
the more common diseases. As Fry argued, it was only through such
surveys of GP records or from national morbidity surveys that it was
possible to 'uncover the extent and form of the vast amount of minor
ill-health in the community' 27 Thus, from a general medicine which
examined grossly deranged bodies with their localised lesions, within a

panoptic structure, general practice began to turn its gaze to the minor, the
transient, the constantly moving illnesses which traversed the social body.
In : 953; Logan, the Chief Medical Statistician at the General Register
Office, published an analysis of the clinical records of eight general
practices during the period April 1951 to March igsa. 28 A report of the
Statistics Sub-Committee of the Registrar-General's Advisory Committee
on Medical Nomenclature and Statistics, entitled The measurement of
morbidity, was published in 195429 and an overview of the findings of The
survey of sickness 1943-1952, by Logan & Brooke, was published in igsy. 30 In
1955, 106 GPs drawn from the Research Register of the College of General
Practitioners agreed to record all morbidity in their practices between May
1955 and April 1956 for Logan and Cushion of the General Register Office.
The results were published in ig58. 31
This latter Morbidity Survey - the first major project undertaken by the
newly founded College for General Practitioners - seemed to strike a chord
for many GPs: 'The habit of recording soon grew upon [the doctors taking
part in the Survey] and a curious sense of incompleteness was felt when the
extra records were no longer needed. The habit was so entrenched in some
practices that recording was kept up, using the same methods, long after the
survey year came to an end.' 32 Just as the imperative of the Panopticon was
to analyse individual bodies, a new perception began to command the
surveillance of the social body. The Survey established, in the words of the
College journal, 'a new method of observational research which has
undoubtedly come to stay'. 33
The College of General Practitioners formed an Epidemic Observation
Unit, which, like the studies of Pickles, studied the changing distribution of
various diseases in the community.34 A College Records Unit was proposed
to pursue 'the continued study of total morbidity'. 35 Regional faculties of
the College, when urged to produce some research, carried out surveys: the
South-East England Faculty published its report on epidemic winter
vomiting in I95536 the South-West Faculty, a survey of GP obstetric
cases; 37 and the Yorkshire Faculty, a survey of unrecorded cases of cancer
in I956. 38
Finlay surveyed morbidity in six practices, in ig5439 Horder & Horder
examined 2000 first-time consultations, in I95440 Fry completed a five-year
study of his practice morbidity, in igsS; 41 Backett and his co-workers
described the diagnoses made in a practice of 3000 in one year;42 Crombie
surveyed his own practice, in I957;43 Theakston carried out a 'social
survey' of his country practice during six months of igsS;44 in 1959
Handfield-Jones reported on one year's work in general practice,45
Bancroft, on a survey of patients with chronic illness in a general practice,46
and Crombie, on a casualty survey.47 Within a few years the survey was
being used to examine many facets of general practice and in so doing
transformed its cognitive base.
The technology of the survey potentially enabled post-war general
practice to monitor the community over time and to map its distributions
over space. It became possible to envisage that the very earliest manifesta-
tions of disease in the community might be identified: the GP for instance
was 'undoubtedly in an ideal situation to make useful observation and
valuable records of 'the very earliest phases of stress disorders and
psychiatric illness'.48 It also became apparent that 'continuity of observa-
tion is one of the advantages of general practice'49 - continuity over time,
over diseases, over patients and over social networks.
With the gradual extension of the survey and the increasing deployment
of the community disciplinary gaze in the post-war world, an outline of a
respatialised medicine began to emerge; a new map came into focus on
which could be plotted new diseases, practices, effects and specialties. At
the point where a concern with childhood intersected various techniques for
the observation of normal children, a new paediatrics emerged; at another
point there was a new configuration in the field of mental illness from where
a revitalised psychiatry crystallised out its new shape and concerns.
Similarly, at the point where the survey, which uncovered 'ordinary'
diseases, and the imperatives of continuous community observation came
together, the conditions were created for a new general practice to be
formed. These realignments in the broad field of medicine in the
community did not occur instantly and, indeed, are far from accom-
plished to the present day - but in the early post-war years the possibility of
an alternative form of practice, a transformed problematic, a new gaze,
began to be felt in the traditional domain of the GP. New 'conditions of
possibility', to use Foucault's phrase, began to influence the production of a
new discourse in general practice which, in its turn, began to have various
effects on social and institutional practices.50
Thus, in the post-war world, prevention of disease from its earliest
appearances, and continuity of care, became an important claim of the new
general practice. The British Medical Association report on General practice
and the training of the GP, published in 1950, defined the GP's role in terms of
continuous and preventive care and health education and concluded that
general practice 'has as its goal the study of the whole man'.51 Continuity of
care and preventive medicine were identified by the Report of the General
Practice Steering Committee, of 1952 (which proposed a College of General
Practitioners), as 'unique, positive features' in the role of the family doctor
who had previously been defined in essentially negative terms as a
non-specialist.52
The other great discovery (and creation) of the survey in general practice
was the almost limitless domain of the normal and the range of normal
variation. Before the war the GP's function could be seen as 'cure' as in the
hospital; during the war it was to maintain 'fitness and efficiency'; after the
war the GP was faced by 'a mass of apparently unexplained sickness, much
of it undiagnosable and much of it self-limiting' . 53 Post-war general practice
developed an extensive discourse on the normal and its variation which
manifested itself in a variety of often seemingly contradictory positions.
First, there were those GPs who wanted to use the survey as an
instrument for prising apart the apparent continuity between illness and
normality. Pinsent couched the problem in terms of distinguishing the
trivial from the normal. 'Only by observing the course of diseases and their
natural history can we learn the full significance of each departure from
normal.' 54 Furthermore, through the survey, it would be possible to
establish the order and frequency of illness in the community which could
then be used as a reference point. 55
The need to separate the normal, the trivial and 'real' illness also
underpinned the arguments of those in general practice who, throughout
the 19505 and 19605, complained that general practice was being over-
whelmed by 'trivia'. Over-use of services for trivial complaints was
commonly believed to be general; 56 patients were seen to demand services
'if their minor symptoms have not subsided in ten days'; 57 the GP was
thought to have been reduced to a 'mere signpost and disher-out of
placebos'. 58
This new discourse on the extent of minor and trivial illness, which came
to preoccupy much of the general practice literature during the 19505,
also found expression in the proposed rejection of traditional medical
diagnostic categories so as to enable these new phenomena to be measured.
An editorial, in 1955, in the College of General Practitioners' Research
Newsletter argued 'might not we GPs accept the fact that health is a state in
which variations from the normal or average may occur without disease
necessarily being present?' 59 GPs who attempted to measure morbidity in
their practices, increasingly found themselves accepting the seeking of
medical advice60 or 'spells of sickness' as the criteria of morbidity. 61 In
effect, patient-based criteria began to replace nosological referrents in the
identification of illness.
Another clement in the perception of the new general practice, which the
survey engendered, was the final conflation of normality and abnormality.
This first presented as a methodological problem. It was found - so it was
claimed - that in the Survey of Sickness, under intense questioning, 'most
people could be got to confess to some minor complaint'. 62 The method-
ological problem, however, was rapidly transposed into a conceptual one:
8o Political anatomy of the body
might not symptoms, as the Peckham health centre discovered, be
widespread in the community? Might not those who failed to consult the
GP be equally as ill as those who choose to seek his advice? Was the
so-called normal, truly healthy, or did the normal move in and out of
illnesses in the community beyond the immediate clinical gaze? Were the
findings of the Survey of Sickness methodological artefacts or did they
represent a correct view of 'normal' health?
In their survey of 2000 first-time consultations, carried out in 1953,
Horder & Horder also visited 98 randomly selected families and noted
their morbidity. It seemed from these findings that perhaps two-thirds of
patients' illnesses went unreported to the GP. Horder & Horder com-
mented: 'This result may seem a little difficult to believe.'63 Yet this
discovery was supported by Backett who, in his survey of 16000 con-
sultations, also arranged for a random sample of 101 families to be visited
for six months by social workers to record their morbidity.64
In parallel, particularly under the influence of American research,
medical sociology discovered 'illness behaviour'.65 Surveys were carried
out, often with doctors, of the perception of illness and use of services in the
community.66 Symptoms and illness were found to be relatively common
occurrences and use of services unrelated to severity. A recurrent problem
with these studies was the interpretation to be placed on the apparent
variability in reporting of symptoms, according to period of recall, mood,
context, etc. At first, these problems were treated as methodological in
nature - something essentially to be overcome to establish 'true' morbidity;
later, they were interpreted as signifying the very essence of the non-
localisable, shifting, transient symptomatology which both defined and
characterised the social body.67
The psycho-social context

The survey established morbidity as an ephemeral point at which patient
characteristics, relationships and context manifested themselves. It also
focused medical attention on those very peculiarities of the social body
which brought morbidity - especially the minor and trivial - into, albeit
brief, relief.
The newly formed Section of General Practice at the Royal Society of
Medicine held a discussion on 'What is general practice?', in 1950. It was
argued that 'the essence of general practice is to live amongst your patients
as a definite cog in the whole machine, knowing them so well both in health
and in sickness, and from birth until death'. The new 'discovery' of social
medicine as human ecology was commended as showing that there was
more to medicine than hospital practice. If the GP was to know properly
Disciplines of the survey: j. general practice 81
and treat his patients then the patient's 'parents, his family life, his home,
his work, his tastes, his recreations' must be studied. Within this context, all
problems thrown up by the interaction, transitory and enduring, of
movements within the social body, were of concern to the GP: 'I believe
there is no case, however trivial, which is completely without interest.'68
The discourse on trivia, which emerged during the 19503, in general
practice, was partly a consequence of the survey, which had discovered
illness to be ubiquitous. Trivia was also, however, the point on which the
new clinical gaze to the psycho-social was articulated. The discourse on
trivia was therefore the product of two elements of the surveillance
apparatus: the survey itself, which mapped the social body, and the gaze to
the relationships within that body. 'In a study of the natural history of
disease, especially where emotions are concerned, it is important to study
the patient against this home background and in his natural
environment.' 69
The survey had shown certain forms of illness to be intimately related to
the social body (which therefore constituted its points of reference).
Similarly, the new 'psychological' gaze rejected illness as an external entity,
a neurological abstraction which invaded the patient's body; rather, it was
an expression of the patient's biography. 'Where the purpose of illness is
important in the patient's life-scheme, attempts to remove it will be in vain
or even "hazardous".' 70 The patient's 'medical history is only a part of the
story, and to consider it alone - as we used to do in the past - is to practise
what the late Dr. Crookshank called Farm-Yard Medicine'. 71
During the 19508, therefore, a reconstruction began to take place in
aspects of the GP's role. The importance of the GP as friend, guide and
counsellor was continually stressed;72 the history of general practice was so
constructed to promote a vision of a distant era in which 'deep insight into
family life and character' constituted the essence of a well-regarded general
practice. 73 Emotional illness, stress and psychotherapy, it was argued, were
integral elements of any general practice.74
This analysis of the work of the GP found its full theoretical expression in
the work of Balint, published in the igsos.75 Balint argued that the medical
gaze in general practice should not be directed to the interior of the body
but outwards to the patient's ever-changing social context. The function of
the doctor was to listen and form a relationship - not with a passive object
but with a patient as subject. The examination of the psycho-social thus
functioned as a mechanism for seeing and treating the patient as a subject.
The discovery of the 'relationship' between doctor and patient and the
importance assigned to it, assumed a coming together of subjects whose
behaviour and attitudes would mutually affect one another. 76
Moreover, the reasons for visiting the doctor were reconstrued in terms of
'unorganised illness' which required ordering. The whole configuration of

illness, patient, and doctor was therefore rearranged, and from it emerged
the 'problem' of trivia and the gaze to the subjective patient since it was the
patient's meanings, decisions and subjective world which triggered the
decision to consult rather than the dictates of a localised, organic
pathology. As Horder claimed, several years later, when describing the
influence of Balint, 'since each patient is unique, diagnosis must be like
biography and is inseparable from treatment'. 77
The organisation of general practice

The new extended clinical gaze embodied a perception which reconstrued
various aspects of illness - its nature, its forms, its temporal orderings and
its distributions; it enabled illness to be seen in terms of the incessant
movements within a social space and thereby brought about a reassessment
of the identity of the patient. But it was also a mechanism, a particular
technology, for both creating and monitoring these new phenomena. Thus
the survey emerged as both a component of, and means of realising, a
community disciplinary apparatus, and the consequent constant gaze over
the population found its expression in the emergence of new institutional
arrangements in general practice.
As a mechanism for monitoring the community, the gaze had to examine
'normal' people, it had to map social relationships and illness distributions,
it had to extend itself physically from a medical-centre to a community-
periphery. Health centres provided one element of this structure. Health
centres had been proposed by the Dawson Report of 1920 as points of
coordination between hospital and community and as the base for
domiciliary services. 78 The Peckham health centre - though in many ways
eccentric - had realised some of these proposals and the National Health
Service Act, of 1964, suggested further extension of the health centre ideal. 79
In the event, it was to be almost two decades before health centres
became widespread; only a handful existed during the 19505 though it was
alleged that in these, when they were successful, a 'spirit of enterprise and
the "new look" in social medicine dominate the scene'. 80 The delay in
establishing health centres was mainly due to resistance by GPs. A postal
survey by the British Medical Association, in 1951, discovered only 38% of
GPs supported health centres; yet a few years earlier, during the war, a
majority of GPs had declared themselves in favour in a similar survey. 81
The effect of the war on GP perception was important. The war had
imposed a panoptic structure on the whole community in terms of a
constancy of surveillance and monitoring. The survey had emerged during
the war as an instrument of observation; the emergency health service had,
Disciplines of the survey: jj. general practice 83
for the first time in Britain, offered a comprehensive health care system to
the whole of the population. Within this integrated community the idea of a
health centre could therefore be seen positively, as an institutional
arrangement which might further these various processes of mapping and
maintaining the social body. Within the armed forces, on the other hand,
with even closer integration and more pervasive surveillance and disciplin-
ary mechanisms, support for health centres was even more enthusiastic: of
doctors serving in the armed forces, 83% voted in favour of returning to
health centres.82
When the war was over and the disciplinary machine which had
embraced a whole society was relaxed, the appeal of health centres
diminished. It was only with the more gradual extension of generalised
surveillance techniques into general practice during the 19505 (in terms of
the survey and the psycho-social gaze), and the removal of financial
impediments in the ig6os, that the health centre could once more be seen as
an ideal institutional mechanism through which to deliver good general
practice. 83
Health centres, when they came to be built, enabled various elements of a
Dispensary-like apparatus to be institutionalised. First, they offered the
opportunity for integrating all community medical services. They enabled,
for example, local authority clinics - some of the original manifestations of
the Dispensary to be integrated with general practice. Thus Edwards
reported child health clinics, school clinics and family planning clinics
within health centres in Devon.84 Second, health centres made special
provision for certain essentially 'normal' population groups, perhaps a
retirement clinic, an obesity clinic, a motherhood clinic and, more
specifically, for clinics to be devoted entirely to screening and surveillance,
for example diabetes clinics and hypertension clinics. Finally, the health
centre provided a base and point of communication for the growing 'health
care team' which, particularly in its community role, enabled medical
observation to be further extended.
The general practice 'health care team' was an invention of this same era.
In the late 19505 and early 19605 there were less than twenty 'attached'
health visitors, district nurses and midwives in the whole country. 85 More
attachment schemes were advocated by the Gillie Report of 1963. 86 By the
beginning of 1969, 25% of district nurses, 29% of health visitors and 15% of
midwives employed by the local authority were working in attachment
schemes (in all, several thousand paramedical staff being involved). 87
The Gillie Report saw the functions of the GP as threefold: as a 'first-line
defence' in the health service, as an intermediary between patient and
specialist, and for mobilising and coordinating health and welfare services.
It was particularly in respect of this latter function that Gillie believed that
attachment schemes would be beneficial. 'The borderline between medi-
cine and social science lies in general practice', and it was as an aid to
managing this area of preventive care, personal relationships and public
health, that nurses, health visitors and midwives would be invaluable. 88
The need for further 'ancillary help' formed a central plank in the struggle
over the GP's Charter in ig65 89 and, as attachment schemes became more
common, so the health care team became the normal context of general
practice work. Drury, after a year as Nuffield Travelling Fellow in general
practice, concluded 'This concept of the future pattern of general practice
in Great Britain is widely accepted.' 90
The health care team, however, did not usurp GPs' functions - as it was
at first feared - but extended their range. As Fry argued 'nurses and health
visitors working with general practitioners increase the scope of their work
but this increase is not through delegation or dilution of the responsibility of
the doctor' 91 They would work, like the GP, with the 'common diseases of
the community' The nurse could become involved in screening and
diagnostic procedures, the health visitor, as the medical social worker of the
practice, could be the 'contact girl' with other services and its activist in the
social, preventive and educational aspects of medical care and welfare. 92
The health centre and the health care team were components in a
network of surveillance that discovered, identified and monitored the
common disease, the minor symptom, the transient illness which hardly
marked the body of the patient. The trivial became important, not because
it suddenly appeared and apparently threatened the very existence of
general practice, but because it was born at the point of intersection of
various lines of force which now traversed the conceptual, social and
institutional domains of medicine.
The survey both discovered the trivial and also enabled it to be explored,
particularly its distributions, both spatially and temporally. The psycho-
social gaze, which sought to encompass the intimacies of social rela-
tionships, came to rest especially on patient problems in which particular
localised, organic pathologies were absent. The replacement of the norm by
the normal threw into relief the problem of trivia as an instance of normal
variation. The changing institutional arrangements of general practice
enabled the trivial to be encompassed in relation to buildings, in the context
of special clinics, and by the extended medical arm of the health care team.
General practice was in a position to desert the detailed, reductionist
analyses of the Panopticon and to turn its gaze to the casual movements and
the brief appearances of illnesses within a social body.
9
Disciplines of the survey: 4. geriatrics
Geriatrics was a specialty born directly of the survey. Its first stirrings were
in 1935 when Warren surveyed the morbidity among older patients in an
old Poor Law infirmary; 1 but as a subject with a specific identity it can
probably be dated to Sheldon's classic survey, of IQ48. 2 It was the latter
survey, together with similar surveys in the following years, which
established the outline of a new discipline and at the same time constituted
the basis of its cognitive framework.
In 1944, the Nuffield Foundation had sponsored a survey of old age
under Seebohm Rowntree. Published in 1947, this survey examined old
peoples' incomes, housing, living conditions, recreation, employment, etc. 3
Investigation of the medical condition of old people, however, was
entrusted to Sheldon, a hospital physician in Wolverhampton. Sheldon
took a random sample of I in 30 old people living in Wolverhampton - in all
some 583 people - visited their homes, recorded their living conditions and
relationships and made an impression of their physical state. The result was
the first record of the health of a normal community of the aged. 'It is hoped
that this short description of some of the physical and social problems
connected with old age may bring home the fact that this is a branch of
medicine in which simple, direct observation can still pay an ample
dividend.'4
Yet this survey was not observation in the usual clinical sense.
Observation in medicine belonged to a certain structure of perception (the
Panopticon) which analysed and described enclosed bodies. As Sheldon
pointed out, medicine usually deals with the ill or possibly ill and therefore
assumes these typical of the whole. But the community random sample
revealed :'Those individuals who are ill and know they are ill, but have no
intention of doing anything about it, as well as those who never have been
ill.'5
Yet, interesting as the findings certainly were, it was the technique that
held the greatest fascination for Sheldon. The random sample survey made
accessible and intelligible to the medical gaze that which had remained
hidden. 'Perhaps one of the deepest impressions left in my mind after
85
conducting the survey is the fundamental importance of the random
sample.' 6
Other surveys followed that of Sheldon. In 1955 Hobson & Pemberton,
in The health of the elderly at home, reported a similar survey of the health of old
people. 7 Thompson, Low & McKeown reported a health survey of old
people in Birmingham, in 1951.* Ferguson studied 300old people receiving
domiciliary care in Glasgow. 9 Prompted by the appearance of the health
problems of old age in the field of medical visibility, many regional health
boards established geriatric advisory committees, some of which, in an
attempt to identify the extent of the problem of illness in old age, conducted
their own surveys. Sheffield Regional Health Board, for example, carried
out a survey in 1950 and published it in 1951. 10 'So much knowledge of old
age, not only in its medical field but also in its social field, has to be obtained
through surveys', Sheldon pointed out to the 3rd Congress of the
International Association of Gerontology held in London in 1954. 'A survey
is really an aspect of the study of natural history'. 11
A temporal gaze
When Sheldon claimed that the survey was an aspect of natural history he
under-estimated the nature and power of the survey. The survey was not
simply a mechanical technique, but a technology through which power
operated as a positive force: the survey created a discourse, a practice, a
reality. In this sense, the survey was not just an aspect of'natural history'
but a means of constituting and sustaining the very conception of'natural
history' as applied to illness.
In traditional clinical medicine, the natural history of an illness was
assessed against the norm: when the illness was worsening, when it was
improving, or when it had disappeared, could all be evaluated against the
constancy of the norm. Within the temporal gaze of geriatrics, however, the
norm was no longer absolute, no longer universal for all ages, but differed
for those aged 7 months, 17 and 70 years. The norm was therefore replaced
as a referrent by the normal. As Agate pointed out 'normal senescence'
could only be identified by establishing whether changes in an old person
were 'normal for his years' 12 (italics in original).
Post-war geriatrics thus stressed a temporal element in the clinical gaze.
Geriatrics was not represented by a momentary frame as caught in the
diagnosis, rather, it established an assessment and surveillance over time
and space which had as its referrent an ever-changing criterion. In
traditional clinical practice, diagnosis preceded treatment, but in geri-
atrics, as Howell observed, 'sometimes prognosis is more important than
diagnosis' 13 The doctor should ask: 'What is the future of this patient?'
Disciplines of the survey: 4. geriatrics 87
(rather than what is the future of this disease). Disease in geriatrics was a
sequence rather than a static entity: 'It is a moving film not merely a still
photograph. What matters most is the direction in which the patient is
going and the speed at which he is travelling. His exact position at any
moment is less important.' 14
The corollary of this perception of illness as a trajectory with constantly
changing referrents was the model of care that geriatrics offered. Geriatrics
differed from general medicine in that it had to 'continue supervision and
management for a long period'. 15 For some geriatricians the specialty was
not so much age- as morbidity-related. 16 Geriatrics discovered the chronic
disease as a model for its practice and, in time, claims were made that it
should be the specialty of disability and rehabilitation and therefore able to
treat the young chronic sick too. 17
It is important to separate the notion of chronicity from the morbidity
group of chronic illness. 'Chronic' is no more than an adjective long used in
medicine to describe a symptom, sign or illness which existed over a long
time period, whereas chronic illness is a recent fabrication of a medical gaze
which played on and between bodies. Thus, while it would be correct to
claim that acute illness has been replaced by chronic disease as the
principal problem of medical practice over the last three decades, it would
be mistaken to ascribe this shift to technological advance and the
elimination of acute infections, as has become fashionable. The problem is,
as always, a political one: medical power has invented a new domain of
illness which both derives from and justifies surveillance over time, yet
medicine cannot be seen to have created its own object. An explanation of
the change in morbidity spectrum has therefore been constructed from
the elements of public knowledge that medicine has available. The notion of
scientific progress establishes a history of an earlier age in which the major
medical problems were acute and of their demise through a technical
triumph whose cost, rather than creation, has been a new morbidity group.
The medical gaze has established a domain of medical reality and with
it the surveillance apparatus of support groups and social networks which
act both to sustain and monitor the new temporally ordered medical
space. 18
Besides the constant surveillance demanded by chronic disease with its
acute exacerbations and temporary remissions- two other aspects of illness
were used to justify geriatrics' monitoring gaze. First, as the survey had
shown, many old people with illnesses chose, for various reasons, not to use
medical services. This 'under-reporting' of illness, various geriatricians
suggested, made screening of so-called 'normal' people particularly
important. 19 Second, in old people, 'illness comes on insidiously with less
clamant symptoms than in the young and in an individual who may well
already have many minor ailments' 20 These various factors - the

ever-changing referrent, the clinical iceberg and the nature of geriatric
illness - taken together, indicated the importance of a comprehensive basis
for the organisation of geriatric services. As Anderson pointed out, geriatric
medicine was clinical, social, preventive and remedial. 'Individuals
discovered in the community must be supervised for life.'21
Unknown illnesses would have to be ascertained, preventive measures
deployed to identify quickly the nascent signs of illness and to encourage
health. 'Prevention of illness is the most important aspect of future work in
the management of elderly people and the methodology of preventive
geriatrics is based on the belief that the self-reporting of illness is not a
satisfactory method of detecting illness at an early stage.'22 Supervision
would need to be carried out by a wide-ranging health care team. Hospitals,
out-patient facilities and community services would need to be closely
integrated to keep a watchful eye over the community of the elderly at risk;
Andrews and his colleagues argued that this integration could best be
achieved around the health centre, particularly if the 38% of old people
they had identified as having unmet needs were to be provided for.23
The geriatric gaze over the domestic, as well as the hospitalised lives of
the elderly, was in part through necessity in that so much chronic disease
existed in the community. However, the geriatrician's concern with the
elderly at home also arose because it was the domestic situation on which
was articulated both the various techniques of long-term surveillance and
the decipherment of the illnesses themselves. Foucault has shown, in The
birth of the clinic, the close parallels with the localisation of the illness and its
preferred place of treatment.24 In the early eighteenth century the hospital
was held to be a place where the nature and manifestations of disease were
distorted: 'no hospital disease is a pure disease ... the natural locus of
disease is the natural locus of life - the family'.25 On the other hand, at the
end of the eighteenth century, when disease had been respatialised from its
general and diverse manifestations in the body to specifically localisable
tissue pathology, there was a concurrent shift in the point of observation
from the home to the neutral domain of the hospital.
In post-war geriatrics, pathology was not so much localised, as in an
open field of perception: illness, as the survey revealed, had an ever-
changing distribution and relationship to the biography and social
relationships of the patient. A hospitalised patient could not demonstrate
how the disease would affect ordinary function nor how the various coping
mechanisms which the patient might draw upon could actually work on
discharge. Surely, Agate argued, 'the best place for elderly people is at
home?'26
The organisational pattern of geriatrics, therefore, reflected the tension
between its origins and principal workload in the hospital and the discourse
which stressed the importance of the home. The day hospital was a device
which enabled both surveillance from a hospital base and the maintenance
of old people in their own homes. 27 Geriatricians encouraged domiciliary
visiting, 'five-day wards' and tended to oppose long stays in hospitals or,
where these were inevitable, to recreate certain features of the domestic
ambience on the hospital ward. It was only in such a setting that the illness
could be correctly observed in its natural context: a slight weakness in
hospital could manifest itself as a functional impairment at home, an
affective disorder might even be a result of the 'distorting' hospital
environment. 28
Moreover, the importance assigned the psycho social context of illness,
its expression and the various modes of coping which it necessitated,
ensured that the geriatric gaze was also exercised over the social
environment. 'Geriatric medicine is more closely involved with the social
circumstances of its patients than is the medicine and surgery of those in the
more active productive age groups. There is hardly a geriatric case in which
the patient's mode of living can be discounted.'29 The geriatric 'method'
required, first, that a patient shall be considered as 'an important
individual with a community identity'; 30 the 'much more recent' idea that
was employed in geriatrics was that 'every individual must be considered in
relation to his environment'. 31
The norm and the normal

The survey was the mechanism by which the essential problematic of
geriatrics was discovered. The survey revealed the distribution of illness in
the community; it enabled need to be identified; it assessed the social
context of illness; it guided the deployment of services. Yet perhaps its
major impact was on the conceptualisation of the normal. Hobson &
Pemberton, in their survey published in 1955, for example, reported that
the relationship between hypertension and symptoms was not as had been
assumed by clinicians; the community survey of morbidity revealed that
hypertension could be present without symptoms and symptoms could be
present without hypertension. They also reported a wider range of'normal'
biochemistry than was usually supposed. 32
This wide range of'normal biochemical values' in the elderly obviously
posed difficulties in interpretation. The problem, in a nutshell, as Jordan
pointed out in 1956, was the difficulty of finding any old person without
some biochemical abnormalities. 33 Consequently, he argued, 'subjects tend
to be chosen as "normal" in respect of a particular investigation because
they suffer from no conditions known to cause that particular investigation
go Political anatomy of the body
to yield abnormal results' Yet, as Jordan was also aware, this procedure
presented a logical difficulty in that it 'supposes a previous knowledge of the
normal values for the particular investigation under consideration'. 34 In
other words, it was a circular argument: normal biochemical values would
be found in normal people who in turn would be defined as having normal
biochemical values.
The survey reconstructed the normal. The survey analysed and
described the characteristics of the social body of old people and, in so
doing, dispensed with the dichotomy of the normal and the abnormal.
Instead, it discovered that old people could be assigned to a point in a
conceptual space characterised by a 'continuous distribution curve' of
health.35
In mapping this conceptual space, geriatrics closely resembled paedi-
atrics and indeed paediatrics provided a useful mode. Geriatrics, it was
thought, could be 'defined in much the same way as paediatrics' 36 and in as
much as it was 'a comparable subject and if it is to be developed both in
respect of research and practice, it will require similar specialised
cultivation'.37 Geriatrics would be a separate discipline from general
medicine 'just as paediatrics developed from the demonstration by Ashby,
Still & Thompson that clinical efforts were frustrated without understand-
ing biological modification by age'. 38 Where growth and development had
provided the crucial cognitive and clinical dimension for paediatrics, so
gerontology, the science of the study of ageing, could underpin the new
geriatrics. 39
Yet gerontology was only one part of geriatrics: the other was clinical
experience as drawn from medicine in general;40 and where gerontology, in
its surveys, discovered the considerable range of normal variation in the
ageing trajectory, clinical medicine attempted to evaluate that same
trajectory by reference to the norm. Geriatrics, therefore, perhaps more
than any of the other disciplines of the survey, created a discourse which
juxtaposed the norm to the normal.
It was clear to Exton-Smith, in his textbook of 1955, that the norm by
which the pathological was to be identified would arise from a 'knowledge
of the physiological (i.e., normal) variation corresponding to the structural
atrophy of organs and tissues'. 41 This particular knowledge, however, was
difficult to establish in that 'such variation may pass into abnormality of
function by hardly perceptible gradation'. Moreover, variations in involu-
tion could at times be so accentuated as to 'become pathological and result
in a state which is obviously a departure from old age'. 42
In his textbook of 1963, Agate similarly stressed the importance of the
normal: 'the first step towards dealing rationally with elderly people is to
have a clear conception of what ought to be accepted as normal'.43 But this
was not easy for 'morbidity increases with age and the physiological shades
almost imperceptibly into the pathological'. The term 'senility', he
suggested, should not be used as it did not distinguish between pathological
processes and the characteristics of physiological ageing.
Isaacs, in 1965, argued that 'the main concern of the geriatrician is to
decide whether a change which he detects in an old person is "normal" or
"abnormal"' - though this distinction could not easily be made. 44
Tunbridge, in 1966, confirmed that there was 'an urgent need to establish
true normals'. 45 Anderson felt that these 'true normals' could be estab-
lished by dividing different ageing trajectories into normal and abnormal
ageing. Though he acknowledged 'that "normal" attributes change with
age',46 he still believed that there existed in old age 'a super class of people
who represent normal ageing almost untouched by disease' 47 Yet how was
this ageing elite to be identified? For Anderson, normal ageing would be
characterised by the 'average values and scatter for all anatomical,
physiological and biochemical attributes ... for as near healthy individuals
as we can obtain'.48 Healthy individuals would define normal ageing while
normal ageing would indicate healthy individuals. Understandably,
Anderson concluded that 'the search for "normality" is still continuing'. 49
By the late 19705, however, this view was under attack. Coni and his
co-authors, in 1977, pointed out that the notion of a 'biological elite' was
misleading in that it represented but one extreme of a continuous
distribution curve of health. 50 Also in 1977, Adams acknowledged that
'differentiation of "normal" from "pathological" ageing is often artificial
but it is useful to distinguish preventable or reversible disease from age
changes which are irreversible and have to be accepted, and it helps to
simplify consideration of the ageing process to think of it in this way'. 51
In 1948, when he carried out his survey of old people, Sheldon assessed
social factors by questionnaire and was 'entirely subjective' in his
evaluation of their physical state. He graded his respondents, normal,
normal-plus or abnormal, in relation to their age. The use of this
'subjective' technique was justified on methodological grounds a fuller,
more 'objective' assessment would have been more difficult, expensive and
time consuming.52 Indeed Amulree, some years earlier, had identified the
difficulty when he noted that: 'When people grow old there is a very narrow
borderline between sickness and health.' 53
Yet what in the immediate post-war years had appeared as an
intransigent methodological problem, had, some 30 years later, been
reformulated as a problem of clinical strategy. The assumptions of clinical
medicine, such that there was a clear differentiation between health and
disease, that diseases existed as separate entities, that disease could be
recognised by clinical and laboratory study, or that precise diagnosis
preceded treatment, were not necessarily true for geriatrics. As Isaacs
argued in 1978: 'the ability to define the "normal" becomes neither a
matter of semantics nor statistics, but a burning issue to be decided afresh
at every clinical intervention'.54
10
A community gaze
The main manifestations of the extended disciplinary apparatus in the

post-war medical world were in certain disciplines which, because of their
proximity to the tactics of the survey, were invested with a new approach to
illness, patients and health care delivery; those parts of medicine -
particularly hospital based - which were components of a panoptic vision,
also started to be transformed by the new procedures of the survey. The
Goodenough Report of 1944 had recommended the establishment of
departments of social medicine within medical schools 1 and it was from
within these departments that a revitalised epidemiology was to emerge
and shape a medical perception of the social.
In 1957 Morris published the first edition of his Uses of epidemiology. 2 In
contrast to clinical medicine, he argued, the unit of study of epidemiology
was the population or group not the individual. Yet, although epidemiology
had the group as its object, it was primarily a method, a way of analysing
and perceiving medical reality. Morris claimed it was a perception which
asked different questions and obtained different answers from those asked
by clinicians. Sometimes, the epidemiologist 'asks questions which the
clinician also asks, and gets different information in reply. Often the
epidemiologists can ask questions that cannot be asked in clinical medicine
at all.'3
Morris suggested that epidemiology had seven separate, though related,
uses in medicine. It could provide historical evidence for changes in
diseases and their distributions, enable the diagnosis of the health of the
community, aid the study of the working of the health service, help
calculate the risks for individuals of various diseases, complete the clinical
picture and natural history of diseases, help identify new syndromes and
search for the causes of disease. The survey, particularly of non-infective
disease, provided the basis of all these various uses.
The chief growth point in epidemiology, Morris suggested, was in
surveys of morbidity: 'the study of morbidity is expanding rapidly and it is
becoming a main interest of Public Health since mortality is progressively
less useful in the diagnosis of public health'.4 Morris himself, in his first
93
published work in 1941, had reported a health survey of a Midlands factory
workforce. 5 The Medical Research Council had surveyed the haemoglobin
of 16000 people in IQ43. 6 Magee & Milligan, in 1951, reported the
haemoglobin levels of 2087 'unselected' women attending welfare clinics
and, from the data, constructed ante-natal and post-natal haemoglobin
'curves'7 . A year later Berry & Magee published haemoglobin levels of a
school population, of housewives 'randomly' selected in the street, and of a
random sample of workers earning less than £1000 per annum. 8
The interim results of a more ambitious project, the ascertainment of all
pulmonary tuberculosis in the Rhondda Valley, were published by
Cochrane and his co-workers in IQ52. 9 89% of the population were
reported to have been x-rayed. Higgins and his co-workers, in 1956,
reported a comparative random survey of 245 men for respiratory
symptoms and pulmonary disability in an English industrial town (Leigh)
to establish whether miners in the Welsh Rhondda had excess respiratory
morbidity. 10 The College of General Practitioners, in one of the first of its
'collective investigations', with the help of the Ministry of Health, carried
out a similar respiratory survey on an age-stratified random sample of
patients drawn from practice lists. 11
In 1952 Getting and his co-workers surveyed a diabetic clinic in
Gloucester. 12 In 1953 Tunbridge reported a survey of patients attending
the Leeds diabetic clinic. 13 Every fifth patient was asked to keep a daily
diary of their diet which was, in turn, monitored by social-worker visits at
the beginning, during and at the end of the survey. Redhead, in 1960, in a
survey of 20% of his practice list, confirmed American reports of 'a
reservoir of undiagnosed diabetes in the practice population'. 14 Walker &
Kerridge reported similar results in a survey from Ibstock, 15 as did
Harkness from Halstead 16 and the College of General Practitioners from
Birmingham. 17 Butterfield & Keen carried out a large survey in a search for
unrecognised diabetics in Bedford in ig6i. 18
Doll and his co-workers reported on the prevalence of peptic ulcer in
different occupations in ig5i; 19 Stewart & Hughes examined the preva-
lence of tuberculosis among shoe-makers, also in ig5i;20 Mial and his
co-workers looked at the prevalence of rheumatoid arthritis in South Wales
in the early ig5os; 21 Pickering and his co-workers reported on the
distribution of blood pressure in a 'normal' population in ig54. 22
This great interest in community morbidity, thought Morris, was but
'one illustration of the modern community's need to know itself, a need
whose wide recognition - anew - represents a striking change in the climate
of opinion.... The more complex a society, the more does it need an
inquisitive intelligence service to diagnose itself.' 23 To this end, the survey
represented the ideal technique and, moreover, Morris claimed, 'the
A community gaze 95
renaissance of sociology ... is opening up the possibility for public health of

an altogether more penetrating social analysis'. 24
For the clinician in hospital practice, these prevalence surveys provided
'accurate information as to the real numbers of diseased people in any
population', thus setting their hospital work load in context. The surveys
could also be used to obtain direct evidence concerning: 'The natural
history of a disease, the true frequency of its various manifestations, or its
association with other diseases, and they may throw light on the aetiology of
a disease.'25 As Witts, the Nuffield Professor of Medicine at Oxford, argued,
one of the main functions of'group research' was to broaden contact with
sick people and to ensure that the clinical scientist's mind remained open to
the major problems of human disease.26
The problem of the borderline case

The increasing post-war medical interest in morbidity (as against mortal-
ity), together with the results of various surveys, created problems of
definition: the counting of deaths was relatively straightforward compared
with measuring illness. In 1966, for example, in a report on the Bedford
survey of diabetics, Keen pointed out that although 4% of the sample had
glycosuria (sugar in the urine - a diagnostic test for diabetes) many of these
'diabetics' did not show an abnormal glucose tolerance curve (another
diagnostic test for diabetes). 27 The question, as Keen noted, was: had the
survey in using glycosuria as the diagnostic test uncovered 'true' diabetics;
or was the abnormal tolerance curve - even in the absence of glycosuria -
the mark of the diabetic? In short, the findings of the survey had led to a
questioning of'our concepts of diabetes as a disease entity'.28
In 1924 Faber had published a book entitled Nosography in internal medicine,
in which he carefully documented the historical rise and triumph of a
particular medical perception which accepted an ontological conception of
disease.29 In classifying various morbid events into disease categories, the
physician believed he was identifying discrete entities existing indepen-
dently of other life forms. Crookshank, an early exponent of the new social
medicine (and of the value of psychotherapy), had challenged this
assumption in 1939, arguing that diseases were but quantitative deviations
from the normal. 30 Nevertheless, at least until the post-war period, medical
opinion held firmly to the belief that diseases or pathology were qualitative-
ly different from the normal or physiological processes which enabled the
organism to sustain life.
By the early 19505, however, various American writers had virtually
dismissed the ontological view: King, for example, argued that 'disease is
an arbitrary designation' 31 , and Riese boldly claimed that 'everyone agrees
that the nosological entity or any other schema is an abstraction'.32 In

England, Ryle challenged the traditional view of the normal, in 1947, with
illustrations of'normal variability'-drawn from various surveys.33 'Health
and disease know no sharp boundary', he claimed, 'variability, both in time
and in the species, is one of the most distinctive and necessary attributes of
life, which thus admits no constant and no norm.' 34 Yet, in 1955, Cohen
could point out that 'the concept of disease as a "clinical entity" still
dominates much of our textbook descriptions' and that minds were 'still
shackled with the concept of disease as "entities'".35 The prolonged and
often acrimonious debate about the nature of essential hypertension,
during subsequent years, was a powerful illustration of the prejudice Cohen
had identified.
In 1954 Pickering and his co-workers published a paper on arterial blood
pressure in the general population.36 Over the next decade, the findings
achieved considerable notoriety and led to a barrage of argument and insult
between some of the leading physicians of the day, such that Pickering
could with some justification claim in the Lancet that, 'nowadays odium
scholasticum is usually discreetly veiled but your readers are being treated
to a splendid display'.37
Pickering recorded the blood pressures of all patients attending clinics for
varicose veins, diseases of the skin, fractures, orthopaedics diseases and
dental treatment at St Mary's Hospital during six months of 1951. He
found that blood pressure in these patients (who, he claimed, were
representative of the general population) showed a normal distribution
rising with age. Moreover, because there was no sharp demarcation
between blood pressures which had traditionally been accepted as normal
and those thought of as being pathological (essential hypertension),
Pickering and his co-workers were 'led to doubt whether there is any
justification other than that of convenience, for drawing a line dividing
normal from abnormal pressure. It would seem in fact, that the term
essential hypertension represents no more than that section of the
population in which the arterial pressure exceeds an arbitrary value and in
which no other disease is found to account for the arterial pressures
observed. According to where we draw the line, so we can make essential
hypertension as common or as rare as we wish.'38
The survey, in mapping the characteristics of a total population, had
uncovered the continuity of its physiological parameters. If so-called
disease states were continuous with general population measurements,
then how could disease be a separate, discrete entity? 'This conception of
the nature of essential hypertension', Pickering noted, 'appears to be a
novel one, though it is so obvious that it is difficult to understand why it has
not been clearly stated before.'39 Against the older notion of separate
A community gaze 97
populations of healthy and ill, Pickering presented the concept of continu-

ous distribution of measurable traits in total populations, and the concept
of normal variability to cope with quantitative differences.
A distinct boundary between physiology and pathology belonged to the
perceptual gaze of the Panopticon which sought to enclose and monitor
deviants; in the new idea of continuous distributions, the normal became
problematic and illness was reduced to the 'semi-philosophical notion of a
physiological abnormality' as McMichael dismissively suggested. 40 It was
precisely this encounter, between a clinical gaze which dichotomised and
the tactics of the survey which uncovered continuity, that focused attention
on the borderline between normality and abnormality. If the discourse
which characterised general practice in the post-war world was on trivia
and that which characterised geriatrics was on chronic illness, then in
general medicine it was the discourse on the borderline case.
As well as undermining the ontological status of the concept of disease,
the borderline case became an accepted category in community prevalence
studies. It was a classification which, in practical terms, made the
problematic boundary between normality and pathology manageable (the
Bedford survey of diabetes classified all blood sugar estimations of 120
200 MG% as borderline cases) 41 and at the same time caused the
researchers to try and sharpen their definitions and research instruments to
minimise the size of this basically unsatisfactory category.
Screening for disease, which had developed in rudimentary form in the
early twentieth-century manifestations of the Dispensary (such as the
school health service inspection clinic), came into more general use with the
post-war discovery through the survey of the vast extent of community
morbidity. Multi-phasic screening was carried out in the United States in
the early igôs42 and reported in Britain in the igGos. 43 In 1968 the Nuffield
Foundation published a volume on the value of screening for different
diseases44 and in the same year Butterfield, in his Rock Carling Lecture on
priorities in medicine, advocated a new emphasis on screening in health
care delivery. 45 Moreover, he discussed the problem of screening for a
continuously distributed variable, only one extreme of which constituted
disease, in terms of controls and borderlines.
Morris, in the second edition of Uses of epidemiology published in 1964,
expanded his section on screening to explore the category of the sub-
clinical. He stressed the importance of penetrating to the 'early minor
stages' and then further back to the precursors of disease and to its
predispositions. Such devices served to further refine certain elements of an
ambiguous borderline which, under certain conditions might remain
essentially normal and under others might translate themselves into full-
blown disease states. 46 The ambiguity was thereafter couched in a new
terminology of screening which identified true positives and false positives,

true negatives and false negatives.
Multiple causes
One of the seven uses of epidemiology that Morris identified was the search
for the causes of diseases. In this section he laid particular emphasis on the
notion of multiple causes rather than on the idea that individual diseases
had single causes - a belief, Morris suggested, which arose from germ
theory in the nineteenth century. The notion of multiple causes was,
moreover, a new discovery: 'the notion of "pattern of causes" is a relatively
modern statement'. 47
In 1942, in a paper entitled 'Aetiology: a plea for wider concepts and new
study', Ryle argued that while Pasteur and other pioneers in bacteriology
had been of immense benefit to medicine they had 'a peculiarly limiting
effect upon the vision and the practice of many medical men'. 48 Specifically,
they had 'compelled a neglect of the associated causal factors without which
no disease can have its being. They also fostered a belief in or search for
single determining causes where none exist.'49
Until the inter-war years the concept of cause or aetiology was
dominated by a search for and belief in a single cause. Models of causality in
medical discourse, such as in Muir's Textbook of pathology (3rd edition,
1 933)> relied on bacteria and viruses: 'we speak of the tubercle bacillus as
the cause of tuberculosis in the sense that the introduction of the bacillus is
ordinarily followed by the disease and that the latter is not met with apart
from the bacillus'.50 However, it was also becoming apparent in the
inter-war years that the notion of a single cause required some qualifica-
tion: a medicine with an extended gaze - especially to the mind and to the
community uncovered other factors apparently causally implicated.
Muir's textbook, in 1933, accepted the need to acknowledge these factors,
though it did so in terms which did not fundamentally challenge the
dominance of single cause theory: 'with regard to many conditions we have
to speak of predisposing, contributing and auxiliary causes' 51
By the sixth edition of Muir's textbook, in 1951, the position had
significantly changed. It was claimed that, with the exception of'certain
infectious diseases, it is no longer supposed that each disease or illness has a
single specific cause which is the sine qua non of the state'. 52 This point had
been made earlier, in the fifth edition of 1941, as far as the aetiology of
tumours was concerned. The cause of tumours, in the 1933 edition, was
held to be largely unknown though 'chronic irritability' was suggested as a
possibility. By 1941, however, a multi-factorial aetiology was clearly stated:
A community gaze 99
'one often hears the phrase "the cause of cancer" but so far as the starting of
the growth is concerned there is no one cause; there are many causes'. 53
Many infectious diseases were acknowledged as having 'multiple causes'
only, by the 1951 edition. For tuberculosis, the claim that the tubercle
bacillus was always present was tempered by the observation that 'the
converse is not necessarily true and the presence of the bacillus is not
invariably followed by the disease'.54 By implication, at least, the disease
had more than the bacillus as its cause. Perhaps the argument was put more
clearly in the general discussion of the cause of pathology (in the 1951
edition) which, while still using the germ-theory model, acknowledged that
'if bacteria arc to be regarded as the seeds of disease, it is now realised clearly
that the soil is also fundamentally important'. 55
Although it took so long to reach the pathological textbooks, the
discovery of the 'soil' in which the tubercle seed could take root had
occurred earlier in the century. The Dispensary vision had discovered the
'soil' of disease when it turned its gaze to the social milieu. A perception
which measured and analysed social relationships and social environments
was also a perception which inevitably invented a multi-factorial aetiology
of disease. It was epidemiologists such as Morris who pressed it on the
profession; the new specialists in social medicine, such as Ryle, who argued
its value; and the techniques of the survey, such as the randomised control
trial, which in the very notion of randomised controls acknowledge the
causal influence of the extraneous variable.
For Ryle, in 1942, the concept of 'multiple factors' was especially useful
in understanding chronic illness because in these diseases, factors such as
'age, sex, habits and occupation' were part of a 'temporal' dimension which
continually sustained and affected the long-term course of the illness. 56
Multiple causes were less important in acute diseases as their 'quick tempo'
allowed so little time for these other factors to have an effect.
The notion of causality belongs, Durkheim would have us believe, with
space and time as the basic categories of human thought which have their
origin in the social milieu. 57 Just as the distribution of the social group
defined space and the ritual of its ceremonies delineated time, so the
experience of external events established causality. When the group was
paramount and individual identity non-existent, causality could only be
seen in fatalistic terms; with increasing individualisation through the
division of labour causality became contingent. Thus a more sophisticated
separation of individual identities and a more complex interactional model
can be read into the invention of multi-causal explanations. Identity was
not given simply by physical separation but also in psychological rela-
tionships through which the effect of one individual on another was both
contingent and reciprocal. Multi-factorial aetiology was an invention of a
i oo Political anatomy of the body
social gaze. 'Much that is truly aetiology' Ryle concluded 'extends beyond
the relatively confined province of pathology and invades the broader
territory of social science.'58 Or, as MacKay noted in 1951, if'the search for
specific (aetiological) agents halted the progress of social medicine then the
role of nutrition, psychological medicine, stress and other trends
reawakened interest in "broader domains of aetiology'". 59
Illness, in the post-war years, began to be temporally and spatially
distributed, not in a physical domain, but in a community. The community
was the term deployed to describe that truly social space that had emerged
in the calculated gap between bodies: a network of interrelated and
interdependent points between which power was exercised reflexively.
Comprehensive health care in Britain, from 1948, and the contemporary
invention and importance placed on community care are simply manifesta-
tions of a new diagram of power which spreads its pervasive gaze
throughout a society.
11
Subjective bodies
The deployment of the new technology of the survey in the post-war

medical world resulted in the crystallisation of new patterns of medical
specialisation. Whereas, previously, medical specialisation had been
structured around the examination, description and analysis of the body of
the patient, the new specialties were deployed in the spaces between
people. In paediatrics the clinical gaze was deployed around the body of the
normal child; in psychiatry it was mainly deployed around the coping
strategies of ordinary people; in general practice the gaze turned from the
grossly pathological to the minor and transient changes in health percep-
tion which hardly left their mark on the body of the patient; in geriatrics the
gaze was deployed over time, in the observation of chronic illness and of the
longitudinal bodily changes which required constant monitoring and
interpretation.
Together, these new specialties created a constant web of observation
around the normal individual and, in so doing, at times coalesced to create
yet more specialties. In 1965, McKeown, in advocating some degree of
specialisation in general practice, suggested four areas in which GPs should
practice: adults, children, the elderly and obstetric cases. 1 The idea of a GP
paediatrician and a GP geriatrician were points at which the new
disciplines of the survey intersected. The GP obstetrician, moreover, was
another amalgamation of two surveillance technologies in that the obstetric
component provided, in its ante-natal care, a constant gaze over a normal
(yet essentially problematic) pregnancy. In the Court Report, of 1976,
paediatrics again extended its reach in recommending specialist GP
paediatricians and a special community role for paediatrics.2 In the same
way, geriatrics in recent decades has reached out beyond the hospital to an
increasing community and domiciliary role.
There were important links between psychiatry and general practice,
especially in the analysis and identification of the neuroses. For many GPs
the bulk of their time is spent practising 'community psychiatry' whilst
psychiatrists show increasing interest in community morbidity and in
holding out-patient clinics in general practice.3 Out of psychiatry and
IO2 Political anatomy of the body
paediatrics has come a separate specialty, child psychiatry4 and despite

its relative low status psychogeriatrics is an established and growing
discipline. 5
If the panoptic vision created individual bodies by objectifying them
through their analysis and description, then the dense web of surveillance
around and between bodies, as shown by the constant gaze of the new
disciplines of the survey and the renewed interest of clinical medicine in the
borderline case, created a mechanism for constituting bodies in a different
fashion. The new body is not a disciplined object constituted by a medical
gaze which traverses it, but a body fabricated by a gaze which surrounds it:
the new body is one held in constant juxtaposition to other bodies, a body
constituted by its social relationships and relative mental functioning, a
body, of necessity, of a subject rather than an object.
The doctor-patient relationship

In 1944 the Goodenough Committee produced a report on medical
education in which the patient was hardly mentioned. 6 To be sure, the
medical student had to be taught how to diagnose disease in his patients,
but the patient was viewed essentially as a passive object in which was
contained interesting pathology. Thus, in the introductory clinical course
in which clinical skills were to be mastered, the Goodenough Committee
emphasised accuracy in recognising the physical signs of disease: 'general
pathological states should be shown and their signs and symptoms
identified on the living patient' 7 (in contradistinction to the dead patient of
the post-mortem room). It was felt that training in 'the taking of a complete
history of a patient's illness' should take place in undergraduate medical
education but no further guidance was offered nor any indication given that
this procedure was at all problematic. Indeed, the form of the interaction
envisaged between doctor and patient was perhaps illustrated by the
comment that at the beginning of the course students rarely know how to
'interrogate' a patient. 8
Some twenty years later, in the Report on the Royal Commission of Aledical
Education (Todd Report), the term 'taking the history' was self-consciously
placed in inverted commas.9 It was pointed out that 'there is a great deal
more to this than simply asking a series of prescribed questions and
checking the accuracy of the answers. Students must be aware of the factors
which impede or distort communication, factors such as limitations of
vocabulary, cultural attitudes and social prejudices.' 10 Between the
Goodenough Report and the Todd Report, the patient can be seen as
entering a new relationship with the doctor- a relationship which might be
Subjective bodies 103
rewarding, important, difficult or therapeutic, but one which some twenty

years earlier had been ignored.
It is in this new discourse around the discovery of an inherently
problematic relationship, after World War 11, that there can be discerned
the lines of a reconstructed doctor-patient interaction and the fabrication of
the patient as a subject. Two lines of analysis of the doctor-patient
relationship can be identified: the first concerns the mapping of the social
space between doctor and patient, the second, the crystallisation and
localisation of the 'problem' within that space.
Communication across a social space

From its foundation, in 1925, the British Journal of Venereal Diseases was
dominated by papers on the clinical and pathological aspects of venereol-
ogy. The total lack of mention of the patient in the early years as other than
the carrier of pathology, reflected the irrelevance of the patient's individual-
ity for the practice of venercology. In 1932, however, the patient received
separate mention for the first time. Frazer, in a paper entitled 'The problem
of the defaulter', analysed 50 replies to a questionnaire he had sent to a
group of defaulters from VD treatment. 11 He concluded from his study that
it was important to 'impress on all patients at intervals the necessity of
treatment' and that the patient should 'repeat all directions so no
misunderstanding can occur'. 12
In Foucault's analysis of the emergence, towards the end of the
eighteenth century, of the body as an object which could be used,
transformed and rendered docile, part of the mechanism by which passivity
was achieved was the newly discovered clinical examination. 13 In that the
clinical examination involved an invasion of 'private' body space, in that it
involved an analysis and dissection of the body and in that it subjected the
whole body its surface, its crevices, its insides, its workings to a medical
gaze, then the body (and hence the patient) was constituted as a discrete,
though passive, object. The clinical examination thus fabricated the body
and through its rituals privatised it and made it passive. If the patient
accepted this gaze then its effects were achieved yet even resistance to the
gaze produced the same result because resistance was itself based on the
notion of the body as a discrete and personalised object. Thus the body was
held in, and constituted by, a field of surveillance from which it could not
escape.
In Frazcr's paper on defaulters, however, the body is analysed in terms
other than passivity. In addition to being the docile carrier of disease, the
patient achieves a tentative identity as a potential defaulter. The patient is
not simply an object which will conform; it possesses, in its potential for
default, a germ of idiosyncracy. Hence derived the need, as expressed in
Frazcr's concluding advice on how to manage this danger, to begin to treat
the patient as other than a wholly passive body, albeit one which, with the
correct instructions, could be made passive.
In 1935, in the same journal, a series of four papers on default were
published. Hanschell reported on 'The defaulting seaman', 14 Nichol on
'The defaulting prostitute' 15 and 'The defaulting travelling man', 16 and
Nabarroon "The defaulting child'. 17 In 1947 MacFarlane & Johns reported
'a medico-social analysis of 381 women patients' in an attempt to locate
venereal disease defaulters from a social point of view. 18
The perception of the patient as an actual or potential defaulter,
represented a constant theme in post-war literature on the doctor-patient
relationship. Yet within this continuing concern with default can be
discerned the subtle changes through which the patient was being
reconstituted. First, the negative, pejorative 'defaulter' was reanalysed in a
much more complex and subtle discourse on 'compliance' suggesting that
obedience to medical advice could not be so starkly assumed. The patient
was thereby transformed from someone who simply failed to follow advice
to someone who chose whether or not to follow that advice. In this latter
formulation, the element of choice stands in contrast to the docility of the
patient as conceived in traditional medical discourse.
In an overview of patient non-compliance, in 1976, Ley examined four
theories. 19 First, there was the 'personality hypothesis' which argued that
non-compliance was a function of personality, attitude or demographic
characteristics. Ley pointed out, however, that evidence in support of this
hypothesis was weak; in addition, even if such links were to be 'incontrov-
ertibly established, knowledge of them is of little practical use'. 20 The
remaining three theories he claimed were more useful. The psychodynamic
hypothesis posited that non-compliance would result if the 'deep' problem
was not tackled; the interaction hypothesis placed the problem within the
process in which doctor and patient negotiated the interview; the cognitive
hypothesis (which Ley supported) presented the problem as one of memory
and/or understanding.
In all these theories, however, there was a common element: the central
problem was cast as one of communication and it was assumed that
patients' dissatisfaction and non-compliance were directly a result of
communication difficulties. In the 19605 and 19705, therefore, the older
problems of default and compliance became points on which were
articulated the new concerns with 'effective' communication.
The problem of communication can be traced back to the recognition of
widespread anxiety among patients in the inter-war years. 21 By 1946 it was
believed that anxiety could be combated with adequate reassurance by the

doctor. Cole felt that 'many people today carry unnecessary burdens of
anxiety about their health which limit their happiness and activity', simply
because they had not been given adequate reassurance about their
prognosis. 22 Armstrong, in pointing out the neglect of the management and
handling of patients in the medical curriculum over the previous 50 years,
argued for the importance of allaying patients' anxieties through reassur-
ance. 23 Parkinson thought that patients were inclined towards a 'sombre
prognosis', with consequent undue apprehension, anxiety and fear. 24
By 1960, however, the task of reassuring patients had begun to be
widened. Meares argued that 'the whole business of communication with
the patient is something much more complex than our traditional concept
of history-taking'.25 He pointed to the importance of verbal, extra-verbal
and non-verbal channels of communication between doctor and patient. In
1963 a Sub-Committee of the Central Health Services Council produced a
pamphlet entitled Communication between doctors, nurses and patients: an aspect of
human relations in the hospital service. 2*' The Committee had been appointed in
1961 to improve information flow to the patient, although it concluded that
little was known 'objectively' about patients and their reactions to
treatment. 27 Yet, as the Lancet claimed, the patient needed 'someone he can
call by name who will listen to his troubles, answer his questions and
represent him in the medical world'.28 A year later, in 1964, Cartwright, in
a survey of hospital patients' attitudes to treatment, found that patients
complained of lack of information more than anything else. 29
In his discussion of communication with patients in the Rock Carling
Lecture, 'Communication in medicine', Fletcher took compliance as his
central theme. 30 He provided a brief discussion on 'acquiring information'
but the bulk of the review was on 'giving information'. 'How can we
improve our communication with patients?', Fletcher asked. 'The first
thing is to recognise the problem. Few doctors realise how little of what they
tell their patients may be understood or remembered.'31
Pathology and personality

The second strand in the new discourse on the doctor-patient relationship -
and one which intertwined at various points with the problem of
communication - was that of the shift in location of the medical problem
and the invention of whole-person medicine. Brackenbury announced the
'new relationship arising out of the present outlook of medicine' in his book
entitled Patient and doctor, published in 1935. 32 As Secretary of the British
Medical Association through most of the inter-war period, Brackenbury
had endorsed and espoused a wider 'social work' role for the GP such that
io6 Political anatomy of the body
he held it important that doctors should locate illness in its social context. 33
His view of the medical task was of a relationship between two personali-
ties: 'the relationship between patient and doctor is not merely, between
two persons, but between two personalities.... It is never the body which is
out of health, but always the complete being.'34
Nevertheless, although Brackcnbury advised a relationship of personali-
ties based on whole-person medicine, the patient in his schema remains an
object. In his discussion of'what the patient expects', it is what the patient
expects of the doctor, rather than what the patient expects of the
relationship, which is discussed. The patient is construed as a passive
object, expecting from the doctor certain qualities - knowledge, skill,
carefulness, judgement, sympathy, understanding, moral character, and
ethical conduct. 35 Moreover, the degree to which the 'new psychological
outlook of medicine' was reflected in this new relationship was mainly to be
found amongst general practitioners: the relationship between patient and
specialist, as a product of the referral system, tended to be more 'indirect'.36
Brackenbury's perception of the patient as an object is further evidenced
in his descriptions of what the doctor expects of the patient. Subjectivity,
meaning, idiosyncracy, feelings, a social nexus - themes which were to
dominate certain post-war analyses of the doctor patient relationship
were absent. The doctor expected two responses from the patient,
'obedience and confidence - unless one may properly add as a third, the will
to get better or the will to keep well'.37
Although Brackenbury's analysis of the doctor-patient relationship
might seem somewhat mechanistic, it is representative of a new medical
literature on the doctor-patient relationship which emerged in Britain
during the 19303 at about the same time as the new medical psychology and
its object, the neuroses, became increasingly salient. As the new discourse
on mental instability, the ubiquity of the neuroses and the necessity for a
general mental hygiene spread, so the patient, or at least some patients,
became more than simple repositories of organic pathology. As Raven38
and Campbell39 pointed out, in 1932, the doctor must become aware of the
patient's personality. The patient was not simply an object but a person, as
Crichton-Miller put it, needing enlightenment and reassurance.40
In this reassessment of the patient's identity the psychoanalytic school
had a role. Jones, one of the latter's leading members, observed in 1938 that
'there are few cases in which the unconscious mind of the patient does not
play a part in the clinical situation'.41 Yet perhaps more significant was the
readiness with which other clinicians accepted the new psychology and its
implications for the doctor-patient relationship. For example, Lett, the
President of the Royal College of Surgeons, argued in 1939 that, in the past,
students had had to rely on their natural gifts and instincts in their
relationship with the patient. Now, with the advent of the new psychology
the fundamentals of the relationship- sympathetic understanding, cheer-
fulness and confidence - would need more formal teaching.42
This is not to argue that during the 19305 the medical profession as a
whole were persuaded of the new approach to the patient. Cassidy, for
example, senior physician at St Thomas's thought the new analysis of the
patient's personality a waste of time: 'what a lot of valuable time would be
saved if our patients could be taught that all we want to hear from them is
an account of their symptoms, as concise as possible and chronological!'43
Yet even behind this apparent opposition lay a recognition of a new role for
the patient. The patient could not give a clear history because the patient
was no longer a passive body. The literature which recognised the value of
an obscure history (because it told of the patient's personality), or the
literature which opposed it (because it delayed finding the organic
pathology), both belonged to the same discourse which, in its deployment,
began to destroy the concept of the patient as a docile body.
If the pre-war discourse on the doctor-patient relationship established
the bare outlines of a patient with a personality, then the post-war
discourse, through the increasing respect it accorded that personality,
began to further constitute the patient as subject. In 1948, for example, in
the first paper of its kind in the British Journal of Venereal Diseases, Wittkower
discussed the 'psychological aspects of venereal disease'.44 He pointed out
that he and Cowan, following similar American studies, had been asked by
the War Office to investigate the personality, sex behaviour and 'driving
forces' in a group of patients with venereal disease. He concluded by
emphasising the importance of psycho-social considerations in under-
standing the problem. Wittkower also noted in his paper that he had
written nothing about the patient's reaction to the diagnosis of venereal
disease. This neglect was not because this problem was unimportant: in his
study the patients had accepted the disease, he thought, 'philosophically';
but in civilians, the reaction was important as 'serious concern' was often
expressed. 45 Some two years later, in 1950, in a review of'some individual
and social factors in venereal disease', Sutherland concluded that the social
medicine approach must be applied to the study of venereal disease: 'the
whole patient must be studied and treated as well as his infected tissues ...
every patient is anxious and disturbed'.46
Where the Goodenough Report on medical education, of 1944, had
conceived of the patient entirely as an object, the Report of the Planning
Committee of the Royal College of Physicians on medical education, in the
same year, reflected some of these new concerns. 47 The Planning Commit-
tee stressed that the primary objective of the undergraduate course was to
teach method: 'method for elucidating the facts concerning disease, method
io8 Political anatomy of the body
for welding these facts into an understanding of, and judgement on, the
question at issue, method for testing the validity of this judgement'.48 In
this process the report acknowledged the importance of 'lecture-demon-
strations and practical exercises in the method of history-taking and clinical
examination', though detail was only provided on how the clinical
examination should be taught. 49 Perhaps a clearer indication of the
Committee's thinking was given in its discussion of the place of psycholo-
gical medicine in the curriculum. Recognising that teaching in psychologic-
al matters was by and large defective, the Committee advocated that
greater attention should be placed on 'an acute appreciation of human
nature'; in particular it was felt essential that 'from the beginning of his
clinical career, the student should be encouraged to study his patient's
personality .. .just as he studies his patient's physical signs and the data on
the temperature chart'. 50
Thus, by the end of the 19405, the medical gaze began to fix with more
tenacity on the patient's personality. In 1949, Spence, the paediatrician,
could argue that the 'doctor needs to know the individual ... he must
understand him in many of [his] variations from the norm',51 while in the
same year Cairns, Professor of Surgery at Oxford, could reiterate that the
good doctor 'studies the patient's personality as well as his disease'. 52
By the mid 19505 the patient's personality had become sufficiently fixed
in the medical field of visibility that some of its implications could be
analysed. In 1955 Balint published a classic paper on 'The doctor, his
patient and the illness' 53 (later expanded into a book of the same title54 ), in
which he outlined some implications of the patient-as-subject for under-
standing patient behaviour and reactions to the doctor. In the same year,
Jarvinen, in a paper entitled 'Can ward rounds be a danger to patients with
myocardial infarction?', argued that a higher mortality rate after a ward
round might be caused by the patient's reaction to the psychological
strain;55 Ellison tacitly acknowledged the existence of the patient in a social
network when he presented arguments in the Lancet for the importance of
managing the coping problems of the patient's relatives; 56 and Clark-
Kennedy, in pointing out the active part the patient must play in keeping
healthy, effectively denounced the perception of the patient as a passive
object. 57
Whereas earlier the diagnostic function of medicine had created
categories of patients with different diseases, the new medical gaze, which
created a web of observation and concern around the idiosyncratic patient,
established an individual identity. This is illustrated in venereology where
Rogerson, for example, in 1951, identified vcnereophobia in certain
patients: 'to the sufferer it is often more distressing than a real attack of
gonorrhoea or syphilis to the average patient'. 58 In 1952 the Venerologist
Group Committee of the BMA, following a questionnaire sent to all

venereologists, pronounced on the importance of social workers being an
integral part of the venereal disease service. 59 In 1953, Home, in an analysis
of the 'contemporary defaulter', offered a more complex view of the
problem than his predecessors some years earlier. 'The behaviour of
persons under treatment and observation ... should be considered in
planning the management of such patients.' 60 Thus gradually, the patient
with venereal disease was reconstrued: from being simply a member of a
particular group, he became an individual with unique characteristics. To
be sure, venereal disease was still found to excess in the promiscuous, but it
was now recognised that 'the promiscuous spring from every class of society
and every type of home'. 61 Some people resisted the pressures on them,
others did not, 'the individual character and psychological make-up
being the determining factor. Each girl travels her personal byway to
promiscuity.' 62
In 1966, in a series of articles in The Practitioner, under the general heading
of'The doctor-patient relationship', Browne & Freeling offered a formal-
ised analysis of the interaction between doctor and patient. 63 The articles
were republished as a book in 1967 and a second edition was published in
igyS. 64 In their writing, Browne & Freeling endorsed 'whole problem care'
as the task of medicine, with the GP's role specifically 'to understand the
whole of his patient's communication so that he could assess the whole
person and be able to consider the effect of any intervention in an illness
upon the whole life of his patient'. 65
This approach was later endorsed by the teaching manual published by
the Royal College of General Practitioners, in 1972, entitled The future
general practitioner, in which the consultation became the axis on which all of
general practice was based. 66 In the same year, a volume of papers from the
First International Conference of the Balint Society, under the title
Patient-centred medicine, further defined and celebrated the new importance of
the patient within the practice of medicine. 67
No better illustration of the enormity of the change that had come over
medicine since the beginning of the century can be given than the changes
in the manuals used for teaching clinical method. Perhaps the most famous
of these is Hutchison's Clinical methods, first published in 1897. 68 The sixth
edition, of 1916, had a brief section on 'the interrogation of the patient' in
the chapter on 'case taking'. There the student was advised to be patient,
allow the patient to tell their own stories (better to reach a correct
diagnosis), not to ask leading questions (except to trap malingerers) and
not to ask the same question twice. The twelfth edition, of 1949, was very
much the same. 69 The sixteenth edition, of 1975, however, stressed the
importance of the patient's social circumstances and commended Balint
11 o Political anatomy of the body
'sensitivity groups' as a means of improving the doctor-patient

relationship. 70 History-taking was not an interrogation but an art and
above all 'a two-way business'. The importance of non-verbal communica-
tion was discussed; the fact that the doctor's touch may be seen as an attack
or a caress was pointed out, and it was stressed that being a patient was an
ordeal: evasiveness, it was argued, might be an expression of anxiety, or a
presenting complaint merely a 'ticket' to gain entry to the relationship. 71
Identity of the patient

In his discussion of the emergence of the 'individual' at the end of the
eighteenth century, Foucault points out that the new (clinical) examination
assured 'the great disciplinary functions of distribution and classification,
maximum extraction of forces and time, continuous genetic accumulation,
optimum combination of aptitudes and thereby the fabrication of cellular,
organic, genetic and combinatory individuality'. In effect, the examination
was 'at the centre of procedures that constitute the individual as effect and
object of power, as effect and object of knowledge'. 72
In similar fashion, the discourse on the doctor-patient relationship over
the last few decades has, like the clinical examination, had an object and an
effect. The clinical examination was a device for ordering bodies, which, in
doing so, constituted them; the medical interview and relationship has
become a comparable mechanism for analysing, and thereby fabricating,
idiosyncratic patients. The medical discourse on default, compliance,
personality, sensitivity, meanings, subjectivity, etc., has not simply been a
device with which to explore certain problematic elements in the doc-
tor-patient relationship: rather, the creation of the discourse has had the
effect of constituting the very problems which it nominally set out to
explore. A discourse on default constituted the patient as a potential
defaulter; a discourse on communication rendered meanings between
doctor and patient problematic; a discourse on personality established the
centrality of patient subjectivity to the medical enterprise; and so on. In
other words, in scrutinising the consequences and implications of accepting
the patient-as-person, the discourse has fabricated that same patient. This
'whole person' is, therefore, the product of a series of smaller discourses (on
compliance, communication, etc.) which, though intertwined, have con-
tributed separate elements to the final perception of the patient as a
subjective body. The result is that the patient can no longer be encapsu-
lated in a single gaze; the whole person is a multi-dimensional rather than
unitary being.
The investing of the body and its relationship with a new mechanism of
power has served to construct a novel range of medical problems and direct
the medical gaze to new areas of concern; and, at these various points, new
or revitalised medical specialties have been crystallised. In other words, it is
neither the prior existence of a corpus of knowledge that allows 'pro-
fessionalisation' in some areas, nor the imperialist construction of an
ideology that serves professional ends, which explains the mutual inter-
dependence of medical knowledge and the profession of medicine, but the
subtle yet pervasive relationship of the body to a mechanism of power in the
form of a system of surveillance.
The manifestations of the relationship between knowledge of the body
and the power that invests it can also be seen in the emergence of many of
the so-called paramedical occupations. The latter part of the twentieth
century has witnessed an expansion in those health workers employed in
community work or the promotion of positive health (rather than simply
disease prevention). The history of health visitors or of health educators, for
example, is another history of the extension of a disciplinary apparatus.
Health educators who, two decades ago, wrote of the effects of telling people
to stop smoking, are now engaged in writing up research which involves
asking people for their individual reasons and rationale for smoking.
The new political anatomy of the body can be seen in the institutionalised
mechanisms of surveillance which have emerged in the last few decades: the
welfare state, the national health service, the current faith in 'community
care' It can also be seen in other non-medical areas such as educational
theories, techniques and institutions; in parole, probation, open prisons,
and community service; in the new techniques and surveillance possibilities
of telecommunications which, as they inexorably extend themselves, evince
an outcry against their threat to a privacy which, in a sense, they themselves
have created.
Yet while the extended gaze of the Dispensary and survey have grown
during the twentieth century, the Panopticon has not disappeared. Prisons,
schools, workshops and hospitals are still built and used: indeed, with the
growth in medical technology and super-specialties, the panoptic gaze has
focused on an even more detailed analysis of the body. Thus, at the same
time as the community gaze constructs identities and relationships, the
Panopticon produces ever more discrete and individualised bodies. At
times it is possible to detect areas of conflict or potential conflict between
these two regimes, such as between hospital and community care, specialist
versus gencralist service, or the struggle for control of childbirth between
hospital obstetrics and community childbirth alliances. 73
But at another level it is important to see these various manifestations of
conflict themselves as the product of a particular mechanism of power and
its accompanying regime of truth. We must, as Foucault suggests, start the
analysis where power is 'capillary ... in its more regional and local forms
and institutions ... at the more extreme point of its exercise'.74 It is at these
points that we can see power in immediate relationship with its field of
application, and where it produces its real effects. It is in this context that
the human body at the end of the eighteenth century enters 'a machinery of
power that explores it, breaks it down and rearranges it. A "political
anatomy", which was also a "mechanics of power", was being born.'75 In
the twentieth century the human body has been subjected to a more
complex, yet perhaps more efficient, machinery of power which, from the
moment of birth (or, more correctly, from the time of registration at an
ante-natal clinic) to death, has constructed a web of investigation,
observation and recording around individual bodies, their relationships
and their subjectivity, in the name of health.
12
Postscript: the human sciences
The extension of a disciplinary apparatus throughout society at the end of

the eighteenth century marked the emergence of a new power, a new
knowledge and a new conception of the body. 'The moment that saw the
transition from historico-ritual mechanisms for the formation of indi-
viduality to the scientifico-disciplinary mechanisms, when the normal took
over from the ancestral, and measurement from status, thus substituting for
the individuality of the memorable man that of the calculable man, that
moment when the sciences of man became possible is the moment when a
new technology of power and a new political anatomy of the body were
implemented.' 1 The sciences of man both biological and human are
therefore separate components of an overall apparatus of power which has
as its object and its effect a particular political anatomy.
At the beginning of the twentieth century the Dispensary gaze trans-
formed a physical space between individual bodies into a social one; at the
same moment Emile Durkheim, the architect of the primacy of the social,
was appointed to the first chair in the new discipline of sociology. These
events are of course not mere coincidents but reflect the development and
deployment in the human sciences of a pervasive gaze to the social, parallel
to that of the medical sciences.
In the early decades of the century, for example, psychology played a
major role in opening up the mind of everyone to surveillance, in
promulgating regimes of mental hygiene, in refining theories of the
neuroses and in creating techniques for explaining and measuring social
relationships. There were undoubtedly many times during the inter-war
years when it would have been possible to observe simultaneously a patient
lying on the psychoanalyst's couch or sitting in the GP's surgery simply
talking about themselves, while a sociologist of the 'Chicago school' was
observing the everyday behaviour of people on the street or an anthro-
pologist who supported the new techniques of field studies was silently
noting the daily routines of some far-off tribe. Throughout society, social
interaction and social space became an object of scrutiny and the confession,
which had been the province of those who demanded secrets, truth and
repentance, was deployed to gain access to the ordinary and the trivial.
The gaze commenced with the child. Psychologists played an important
part in the discovery of the normal child, in revealing the detailed stages of
child development, in classifying behaviour problems and in developing
techniques of educational surveillance and child rearing. Sociologists, in
their exploration of the social world of the child, discovered 'socialisation'
and thereby transformed what had been seen exclusively as a biological
trajectory into a social process.
Sociology made its principal contribution in the post-war world when its
mastery of survey techniques made it of value to a medical gaze intent on
exploring the surveillance possibilities of this newly discovered technology.
Sociologists, in close alliance with medicine, opened up areas of the health
experiences of 'ordinary' people through surveys, of health attitudes, of
illness behaviour, of drug taking and of symptom prevalence.
More recently, as the medical gaze has focused on individual idiosyn-
crasies, personal meanings and subjectivity, sociology too has turned its
attention to fresh possibilities. On the one hand, various survey techniques
have been made more sophisticated so that they might take into considera-
tion, bring out or measure, individual meanings; on the other hand, some
sociologists have explicitly rejected survey techniques on the grounds that
they objectify respondents and have instead turned to methodologies
which, they hold, more clearly respect or enhance patient subjectivity.
Proponents of interaction analysis, participant observations, ethnomethod-
ology, and other more naturalistic methods have, within the last decade,
been critical of the dehumanising aspects of medicine and of sociology itself;
and yet the effect of their stance is to have strengthened the power of gaze of
the new medicine to the essentially subjective.
In psychiatry, sociology has provided a rich and diverse contribution to
the extension of the medical gaze. Methodologically, it has offered
psychiatry various techniques for the exploration of the mental functioning
of individuals, ranging from the survey to participant observation;
theoretically it, together with psychology, has helped to define basic
concepts, such as stress and coping, which have enabled psychiatry to focus
with ever-greater penetration on individual functioning. In short, sociology
has reinforced the shift of the psychiatric gaze from arbitrary external
referrents to internal subjective ones.
In general practice, behavioural scientists have helped in the discovery of
'minor morbidity' through survey techniques; they have promoted the
visibility of the patient by investigating patient attitudes and behaviour;
they have participated in the study of the organisation of care, of health
centres and health care teams, so assisting the extension of the gaze.
Sociologists have supported geriatricians in presenting the problem of
Postscript: the human sciences 1 15
chronic illness as a product of a recent change in the spectrum of morbidity

in the community rather than as an invention of the gaze; and they have
furthered the efficiency of this invention by promoting the study of the
many social implications of chronic illness. In epidemiological studies of
many different medical problems, sociologists have been brought in to help
realise a wider multi-factorial aetiology in which social factors and
environment play an important role. Many of the statistical and methodo-
logical techniques developed by sociologists have further been used in
epidemiological investigations.
In a sense, these many examples are a somewhat arbitrary selection of
points of contact between medicine and the human sciences; in reality,
medicine and these sciences have been engaged in the same enterprise - the
production of a discourse on the individual which corresponds to an
extended disciplinary power. At the same moment as the patient entered
medical discourse as a subject, he appeared in a parallel discourse in the
human sciences; indeed, the changes in medical discourse often preceded
those of the sociological discourse.
When Parsons wrote about the doctor patient relationship in the context
of the sick-role, in 1951, he was reflecting a contemporary medical concern
with the respective roles of doctor and patient. He even specifically
condoned, on theoretical grounds, a relatively passive role for the patient. 2
It is interesting to note that Brackenbury, sixteen years earlier, in his book
of 1935 on the doctor-patient relationship, identified two of Parson's classic
characteristics of the patient's role, obedience to the doctor and the will to
get well. 3 Similarly when Freidson, in 1961, challenged this formulation
and argued that there were objective differences in perspective between
physician and patient and consequently conflicts of interest, he was merely
expressing in sociological discourse what had already begun to be, and was
continuing to be, debated in contemporary medical literature. 4 Again,
Szasz & Hollender's 1956 formulation of the doctor-patient relationship, as
ranging from activity passivity to mutual cooperation, 5 appeared at the
same time as Balint was writing of the same notions.6 And Freidson's
additions to the Szasz-Hollander typology, in igyo7 (when he argued that
the patient might be active and the doctor passive), came some four years
after Browne & Freeling had pointed out how the patient could manipulate
the doctor. 8
Writing in 1975, Stimson & Webb9 agreed with Rubington & Wein-
berg's claim, of 1968, that even medical sociology had tended to treat the
patient as 'objectively given' rather than as 'subjectively problematic'. 10
'We have', concluded Stimson & Webb, 'few accounts of the experience of
the patient as a person.' 11 In effect, the elaboration of patient meanings
in 'every-day medical settings' 12 had become the core of the medical
sociological enterprise during the 19705, at the same time as the various
disciplines of the survey focused increasingly on the same object.
This is not to argue that the human sciences have simply been the hand-
maiden of medicine: their frequent alliances, points of contact and shared
concerns do not reflect a relationship of domination but of a common
object, namely, the body and its relationships, and a common effect, the
subjectivity of that same body. The human sciences have thus produced an
often independent but parallel gaze to the body and within this independ-
ence have forged a new 'regime of truth.' This knowledge has increasingly
been concerned with the subjectivity of experience and has often sought to
conceal its invention through the notion of alienation by presenting
subjectivity as the immanent human condition which the human sciences
have succeeded in 'liberating'.
In a paper published in 1976, Jewson argued that the 'sick-man' - that
being predicated on the idiosyncratic personal experience of the patient -
disappeared from 'medical cosmologies' between 1770 and 1870. 13
Specifically, he argued that the advent of pathological medicine at the end
of the eighteenth century resulted in the prevailing 'person orientated
cosmology' being usurped by an 'object' orientated one. Writing in 1977,
Figlio also saw developments in this period as producing a form of'medical
alienation and reification: people losing a sense of wholeness, inviolability
and ethical judgement'. 14 This suggests that the discovery of the patient in
the medical and human sciences, during the last few decades, was in fact a
rediscovery: that the sick-man had not so much appeared as reappeared.
Yet these studies themselves belong to the human science discourse on the
doctor-patient relationship of the 19705. Perhaps Figlio's sub-title to his
paper should be accepted for what it says: 'an invitation to the human
sciences'
The 'regime of truth' that the human sciences have produced involves an
ethical polarisation of the subject object relationship which privileges
subjectivity as the form of moral autonomy. 15 It assumes that there already
exists 'a human subject on the lines of the model provided by classical
philosophy, endowed with a consciousness which power is then thought to
seize on' 16 Subjectivity might therefore be 'liberated' (by the humane
social sciences) but it cannot be produced by domination; indeed,
domination is held to falsify the very essence of human subjectivity. Hence,
there has been an historical project in the human sciences which has
concerned itself with the identification of a distant disappearance of'a sense
of wholeness, inviolability and ethical judgement' through forces of
repression and domination which then enables claim to be made for the
parallel rediscovery and reappearance of the sick-man, by way of the human
sciences. In effect, the recent social origins of the sick-man are blurred as a
Postscript: the human sciences 117
historical discourse on alienation provides him with a political credo, a
universal status and a plausible history; an invention is translated into a
language of liberation, a positive power which creates is concealed in the
identification of a repressive power which is lifted. As Foucault points out,
we continue to 'describe the effects of power in negative terms: it
"excludes", it "represses", it "censors", it "abstracts", it "masks", it
"conceals" In fact, power produces; it produces reality; it produces
domains of objects and rituals of truth. The individual and the knowledge
that may be gained of him belong to this production.' 17
Political anatomy unifies those various sciences which have as their
common object the human body and its surrounding space. In political
anatomy those disparate knowledges, which have offered seemingly diverse
or contradictory explanations of the body or its behaviour, can be seen as
components of a single apparatus of power. The great debates of the
twentieth century which oppose the individual and the social, the citizen
and the State, the biological versus the environmental, are various
manifestations of the same underlying dream, the same pervasive diagram
of power. On the one hand, the social space around the body delimits and
constrains it; on the other hand, it establishes, for the purposes of
investigation, the reality of the individual as a social being who is able to
manipulate that same social space. The techniques of surveillance are
condemned as offending the individual freedoms that surveillance has
fabricated; the right to private thoughts is celebrated, while, all around,
those same thoughts are whispered in the great confession.
Power assumes knowledge and knowledge assumes power. It is only at
the point where power plays on the body and its extended ontology that
political anatomy is constructed. Perhaps, when Newton picked up a
pebble from the beach and wondered about the great ocean of truth that lay
all around him, his gaze did not veer from the pebble but fixed itself on the
shadowy contours of a stone that had been fashioned by a multitude of
elements.
Notes
Chapter i
1 M. Foucault, The birth of the clinic: an archeology of medical perception, London,
Tavistock, 1973.
2 Ibid, p. x.
3 M. Foucault, Discipline andpunish: the birth ofthe prison, London, Alien Lane, 1977.
4 Unless otherwise referenced the other quotations in this chapter are from ibid,
part HI.
5 M. Foucault, The history of sexuality, vol. i, London, Alien Lane, 1979, p. 94.
Chapter 2
1 H. Williams, A century ofpublic health in Britain, London, Black, 1932, pp. 135-6.
2 S. Churchill, Health services and the public, London, Noel Douglas, 1928, p. 154.
3 H. Williams, A century of public health, p. 146.
Tavisock, 1973.
5 M. Foucault, Discipline andpunish: the birth of the prison, London, Alien Lane, 1977,
p. 198.
6 Ibid, p. 208.
7 See Donzelot for a parallel analysis of the invention of the social: J. Donzelot, The
policing offamilies, London, Hutchison, 1979.
8 H. Williams, Requiem for a great killer: the story of tuberculosis, London, Health
Horizon, 1973, p. 40.
9 E.\V. Hope, Textbook of public health, Edinburgh, Livingstone, 1915.
10 H.W. Hill, The new public health, London, New York, Macmillan, 1916.
11 J.L. Burn, Recent advances in public health, London, Churchill, 1947.
12 H.W. Hill, The new public health, p. 17.
13 G. Newman, quoted in Editorial, British Medical Journal, vol. 2, 1920, p. 709.
14 R. Firth, reported in 'Report on Royal Sanitary Institute Congress', British
Medical Journal, vol. 2, 1920, p. 212.
15 G. Newman, quoted in EDITORIAL, British MedicalJournal, vol. i, 1920^.646.
16 H. Williams, Requiem for a great killer, p. 39.
17 R.C. Wofinden, Health services in England, Bristol, John Wright, 1947, p. 71.
18 G. Bankoff, The conquest of tuberculosis, London, Macdonald, 1946, p. 162.
118
Notes 11 g
19 There had been a general interest in the venereal diseases, especially as they
affected military efficiency and discipline, since the mid nineteenth century. By
the twentieth century this interest had grown to be of more universal concern.
20 W.W. Jameson & F.T. Marchant, A synopsis of hygiene, London, Churchill, 1920,
p. 187.
21 M. Morris, The nation's health: the stamping out of venereal disease, London, Cassel,
1917, p..8.
22 B.A. Towers, 'Health education policy 1916-26: venereal disease and the
prophylactic dilemma', Medical History, vol. 24, 1980, p. 70.
23 Reported in British medical Journal, vol. 2, 1930, p. 155.
24 Reported in Lance, vol. i, 1926, p. 504.
25 Reported in British Medical Journal, vol. 2, 1930, p. 155.
26 Ibid.
27 Reported in British Medical Journal, vol.i, 1932, p. 536.
28 Reported in British Medical Journal, vol. I, 1934, p. 958.
29 Reported in British Medical Journal, vol. 2, 1935, p. 343.
30 J.F. Goodhart, The diseases of children, London, 1885.
31 R. Hutchison Lectures on diseases of children, London, Arnold, 1904.
32 A. Garrod et al., Diseases of children, London, Arnold, 1913.
33 For history see A.W. Franklin, 'Paediatrics 1984', Proceedings oj the Royal Society of
Medicine, vol. 58, 1965, p. 392.
34 H. Cameron, The nervous child, London, Oxford University Press, 1919.
35 Ibid> P- v -
36 Board of Education, Annual report for 1920 of the Chief Medical Officer, London,
HMSO, 1921, p. 109. Quoted in The school health service: 1908—74, London,
HMSO, 1975.
37 The history of the early infant welfare movement is drawn from G.F. McCleary,
The maternity and child welfare movement, London, King, 1935.
38 Ibid.
39 See, The school health service: 1908-74.
40 Ibid, p. 9.
41 Ibid.
42 Quoted in H. Williams, Requiem for a great killer, p. 33.
43 See, for example, E.W. Hope, Textbook of public health (gth edn), 1926.
44 The school health service: 1908-74, pp. 21-2.
45 Editorial, 'Hygiene in school', Lancet, vol. 2, 1926, p. 1173.
46 The school health service: 1908-74, p. 21.
47 See, for example, 'Joint meeting of Sections of Epidemiology and Medicine on
air-conditioning', Proceedings of the Royal Society of Medicine, vol. 30, 1936-7,
P- I54I-
48 J. Watt, 'Ventilation, heating and lighting of hospital wards', Proceedings of the
Royal Society of Medicine, vol. 26, 1932-3, p. 1411.
49 Ibid.
50 W.A. Daley, 'Problems in hospital administration arising out of the Local
Government Act, 1929', Proceedings of the Roy al Society of Medicine, vol. 27, 1933-4,
p. 1445.
120 Notes
51 J.A.H. Brinker, 'Convalescent homes of the future: their type, function and use",
Proceedings of the Royal Society of Medicine, vol. 32, 1938-9, p. 369.
52 J.A.H. Brinker, 'Epidemiology applied to school life', Lancet, vol. I, 1933, p. 569.
53 N. Jewson, 'Medical knowledge and the patronage system in i8th century
England', Sociology, vol. 8, 1974, p. 369.
54 M. Foucault, The Birth of the clinic.
55 W. Hamer, 'The crux of epidemiology', Proceedings of the Royal Society of Medicine,
vol. 24, 1930-1, p. 1425.
Chapter 3
1 L.C. Bruce, Studies of clinical psychiatry, London, Macmillan, 1906.
2 D.K. Henderson & R.D. Gillespie, A textbook of psychiatry, London, Oxford
University Press, 1944 (6th edn).
3 M. Foucault, Madness and civilization, London, Tavistock, 1967.
4 Ibid, p. 246.
5 Ibid, p. 269.
6 M. Foucault, Discipline andpunish: the birth ofthe prison, London, Alien Lane, 1977.
7 See, for example, K. Figlio, 'Chlorosis and chronic disease in igth century
Britain', Social History, vol. 3, 1978, p. 167.
8 The word neurosis was probably first used by Cullen in 1777 as a name for
'generalised affections of the nervous system': W. Cullen, First lines of the practice
of physic, Edinburgh, 1777.
9 First diagnosed by Beard in 1880.
10 M. Craig, Psychological medicine, London, Churchill, 1905.
11 R.H. Cole, Mental diseases, London University Press, 1913.
12 M. Craig & T. Beaton, Psychological medicine, London, Churchill, 1926 (4th edn),
13 P. Stewart, The diagnosis of nervous disease, London, Edward Arnold, 1906.
14 H.C. Thompson, Diseases of the nervous system, London, Cassel, 1908.
15 P. Stewart, The diagnosis of nervous disease, p. 338.
16 W.H.B. Stoddart, Mind and its disorders, London, H.K. Lewis, 1908 (3rd edn:
1919)-
17 Ibid.
18 R.H, Cole, Mental diseases (2nd edn: 1919), preface.
19 HJ. Norman, Mental disorders for students and practitioners, Edinburgh,
Livingstone, 1928.
20 H. Devine, Recent advances in psychiatry, London, Churchill, 1929.
21 A. Cannon & E.D.T. Hayes, The principles and practice of psychiatry, London,
Heinemann, 1932.
22 See, for example, Forsyth's (a general physician) paper on psychoanalysis,
Proceedings of the Royal Society of Medicine, vol. 13, 1919-20.
23 P. Stewart, The diagnosis of nervous disease (6th edn: 1924), p. vii.
24 H.C. Thompson, Diseases of the nervous system (2nd edn: 1915; 3rd edn: 1921).
25 H. Rolleston, quoted in J.R. Lord, The clinical study of mental disorders, London,
Adlard, 1926.
26 M.F, O'Hea, reported in British Medical Journal, vol. i, 1928, p. 221.
Notes 121
27 E.F. Buzzard, 'The dumping ground of neurasthenia', Lancet, vol. I, 1930,

p. i.
28 E.F. Buzzard, 'Medicine and the church', Lancet, vol. 2, 1927, p. 1007.
29 T.A. Ross, 'Morison Lectures', Edinburgh Medical Journal, vol. 42, 1935, p. 445.
30 Editorial, 'Psychotherapy by laymen', Lancet, vol. i, 1939, p. 154.
31 'Annual report on medical education', British MedicalJournal, vol. 2, 1920, p. 371.
32 'Annual report on medical education', British Medicaljournal, vol. 2, 1921, p. 375.
33 'Annual report on medical education', British MedicalJournal, vol. 2, 1922, p. 443.
34 D. Forsyth, 'The place of psychology in the medical curriculum', Proceedings of
the Royal Society of Medicine, vol. 2, 1931-2, p. 1200.
35 'British Association annual meeting', British Medicaljournal, vol. 2, 1928, p. 498.
36 Editorial, 'Psychology in the medical curriculum', Lancet, vol. 2, 1928, p. 559.
37 Editorial, 'Psychology in the medical curriculum', British Medicaljournal, vol. 2,
1928, p. 539.
38 Editorial, 'Psychiatry for future doctors', Lancet, vol. 2, 1938, p. 1474.
39 This requirement was not, however, formalised in the GMC Recommendations
until 1957.
40 Royal Commission on Lunacy and Mental Disorder, London, HMSO, 1926.
41 Editorial, 'The borderland of physiology and psychology', Lancet, vol. i, 1928,
p. 1023.
42 A. Meyer, 'The Maudsley Lecture', Lancet, vol. i, 1933, p. 1129.
43 Editorial, 'Individual psychology', British Medicaljournal, vol. I, 1931, p. 148;
and Editorial, 'Individual psychology', Lancet, vol. i, 1931, p. 249.
44 W. Langdon-Brown, 'Applying knowledge to increase happiness', Lancet, vol. i,
1933, P- 64-
45 W. Langdon-Brown, 'Individual psychology and the sympathetic mechanism',
British Medicaljournal, vol. 2, 1931, p. 753.
46 F.G. Crookshank, 'The psychological interest in general practice', British
Medicaljournal, vol. i, 1932,/». 602.
47 H.V. Dicks, Fiftyyears ofthe Tavistock Clinic, London, Routledge and Kegan Paul,
1970.
48 H. Crichton-Miller, Functional nerve disease, London, Hodder and Stoughton,
1920, chapter i; also H. Crichton-Miller, 'The physical basis of emotional
disorder', Proceedings of the Royal Society of Medicine, vol. 17, 1923-4, p. 27.
49 H.V. Dicks, Fifty years of the Tavistock Clinic.
50 R.G. Gordon, N.G. Harris & J.R. Rees, An introduction to psychological medicine,
London, Oxford University Press, 1936.
51 J.A. Ross, The common neuroses, London, Arnold, 1923.
52 H. Rolleston, quoted in The clinical study of mental disorders.
53 D. Forsyth, Children in health and disease, London, Murray, 1909.
54 J.C. McClure, 'Psychology and the practice of medicine', British Medicaljournal,
vol. i, 1930, p. 610.
55 See next chapter for details of the Peckham experiment.
56 See, for example, Board of Education, Report of the consultative committee on
psychological tests ofeducable capacity and their possible use in the public system ofeducation,
London, HMSO, 1924.
122 Notes
57 D. Armstrong, 'Child development and medical ontology', Social Science and
Medicine, vol. 13, 1979, p. 9.
58 Editorial, 'National Institute of Child Psychology', British Medical Journal, vol. 2,
1931, p. 663.
59 D.R. MacCalman, 'The present status and functions of the child guidance
movement in Great Britain and its possible future developments', Journal of
Mental Science, vol. 85, 1939, p. 505.
60 H. Cameron, The nervous child, London, Oxford University Press, 1919.
61 Joint meeting of Section of Psychiatry and for Study of Disease in Children, 'The
difficult child', Proceedings of the Royal Society of Medicine, vol. 23,1929-30, p. 573.
62 Joint meeting, 'On eneuresis', Proceedings of the Royal ociety of Medicine, vol. 28,
1934-5-
63 A. Garrod et al. (eds.), Diseases of children, London, Arnold, 1913.
64 The school health service 1308-74, London, HMSO, 1975, p. 24.
65 Ibid, pp. 22, 24.
66 R. Hutchison, Lectures on diseases of children, London, Arnold, 1925 (5th edn).
67 Ibid.
68 H.V. Dicks, 'Principles of mental hygiene', in N.G. Harris (ed.), Modern trends in
psychological medicine: 1948, London, Butterworth, 1948.
69 E.F. Buzzard, 'Some aspects of mental hygiene', Proceedings of the Royal Society of
Medicine, vol. 14, 1920 1.
70 D.K. Henderson, quoted in Editorial, 'Social psychiatry', Lancet, vol. 2, 1931,
p. 81.
71 H.V. Dicks, 'Principles of mental hygiene'.
72 M. Culpin, 'A Study of the incidence of the minor psychoses', Proceedings of the
Royal Society of Medicine, vol. 21, 1927 8, p. 419.
73 M. Culpin, 'Occupational neuroses (including miners' nystagmus)', Proceedings
of the Royal Society of Medicine, vol. 26, 1932-3, p. 655.
74 Editorial, 'Industrial hygiene', British Medical Journal, vol. 2, 1935, p. 1678.
75 R.F. Tredgold, 'Mental hygiene in industry', in Modem trends in psychological
medicine.
76 D.K. Henderson, quoted in Lancet Editorials, 1931.
77 F.G. Crookshank, 'The psychological interest in general practice', British
Medical Journal, vol. i, 1932, p. 599.
78 J.C. McClure, 'Psychology and the practice of medicine', p. 610.
79 T.F. Rodger, 'Personnel selection', in Modern trends in psychological medicine.
80 Editorial, 'Psychiatry and the services', Lancet, vol. i, 1940, p. 839.
81 The works of psychologists and psychiatrists in the services, London, HMSO, 1947.
83 'Annual medical education review', British Medical Journal, vol. 2, 1932, p. 479.
84 E. Glover, 'The birth of social psychiatry', Lancet, vol. 2, 1940, p. 239.
85 A.A.W. Petrie, 'History of psychiatric developments', Journal of Mental Science,
vol. 91, 1945, p. 267.
86 Editorial, 'Intolerance in psychiatry', Lancet, vol. 2, 1931, p. 1089.
88 Editorial, 'Expanding psychotherapy', Lancet, vol. i, 1936, p. 1078.
Notes 123
89 M. Culpin, 'Psychology in medicine', Lancet, vol. 2, 1945, p. 519.

go J.R. Lord, The clinical study of mental disorders.
91 M. Craig & T. Beaton, Psychological medicine.
92 R. Worth, 'Four decades of psychiatry', Journal of Mental Science, vol. 81, 1935,
P- 755-
93 R.A. Noble, 'The place of psychology in medical education', Journal of Mental
Science, vol. 78, 1932, p. 793.
94 H.V. Dicks, Fifty years of the Tavistock Clinic.
95 Editorial, 'Royal Medico-Psychological Association at Oxford', British Medical
Journal, vol. 2, 1930, p. 69.
96 Editorial, 'Psychiatric clinic at Guy's', Lancet, vol. i, 1939, p. 996.
97 Editorial, 'Psychiatry and general medicine', Lancet, vol. 2, 1942, p. 128.
98 Editorial, 'Psychiatric training', Lancet, vol. 2, 1943, p. 294.
99 R.H. Cole, Mental diseases.
100 D.K. Henderson & R.D. Gillespie, A textbook of psychiatry.
101 D.K. Henderson, reported in Editorial, 'Controversial ground in psychiatry',
Lancet, vol. I, 1939, p. 654.
102 Editorial, 'Research in psychiatry', Lancet, vol. i, 1935, p. 1223.
103 D.K. Henderson, quoted in Lancet Editorial, 1939.
Chapter /
1 Consultative Council on Medical and Allied Services, Interim report on the future
provision of medical and allied services (Dawson Report), London, HMSO, 1920.
2 Ibid, para. 51.
3 Ibid, para. 90.
4 Interdepartmental Committee on Insurance Medical Records (Rolleston Report),
London, HMSO, 1920. These issues are discussed by F. Honigsbaum, The
division in British medicine, London, Kogan Page, 1979, p. 94.
5 Dawson report, para. 136.
6 Ibid, para. 137.
7 J.B. Atkins, National physical training, London, Isbister, 1904.
8 Syllabus ofphysical trainingfor schools, London, Board of Education, 1909 and 1919.
9 Ibid, p. 4.
10 Ibid, pp. 8-10.
11 Dawson Report, para. 141.
12 Quoted in Editorial, 'Newman lecture on public health', British Medical Journal,
vol. i, 1920, p. 646.
13 Quoted in Editorial, 'Health through ministry', British Medical Journal, vol. 2,
1920, p. 709.
14 F. Honigsbaum, The division in British medicine, p. 147.
15 The 'Peckham experiment' led to a stream of publications. Two important
books to emerge were: Biologists in search of material: an interim report on the work of the
Pioneer health centre, Peckham. London, Faber and Faber, 1938; I.H. Pearse & L.H.
Crocker, The Peckham experiment: a study in the living structure of society, London,
George Alien and Unwin, 1943.
124 Notes
16 I.H. Pearse & L.H. Crocker, The Peckham experiment, p. 12.

17 Ibid, p. 13.
18 Annual report, Pioneer health centre, 1935-6, p. 9.
19 Biologists in search of material, p. 48.
20 Annual report, Pioneer health centre, 1935-6, p. 8.
21 I.H. Pearse & L.H. Crocker, The Peckham experiment, pp. 79-92.
22 Biologists in search of material, pp. 43-4.
23 I.H. Pearse & L.H. Crocker, The Peckham experiment.
24 J.M. Last, 'The iceberg: completing the clinical picture in general practice',
Lancet, vol. 2, 1963, p. 28.
25 See, for example, D. Mechanic, 'The concept of illness behaviour', Journal of
Chronic Diseases, vol. 15, 1962, p. 189.
26 Annual report, Pioneer health centre, 1935-6, p. n.
27 I.H. Pearse & L.H. Crocker, The Peckham experiment, pp. 76-7.
28 Ibid, p. 68.
29 Ibid, p. 83.
30 J.A. Ryle, Changing disciplines: lectures on the history, methods and motives of social
pathology, London, Oxford University Press, 1948, p. i.
31 Ibid, p. 2.
32 Ibid, p. 4.
33 Ibid, p. 24.
34 Social and Preventive Medicine Committee of the Royal College of Physicians,
Interim report on the teaching ofsocial and preventive medicine, London, Royal College of
Physicians, 1943.
35 U>id, p. 3.
36 Ibid, pp. 13-15.
37 N.M. Goodman & C. Morris, 'The clinical teaching of social medicine',
Proceedings of the Royal Society of Medicine, vol. 33, 1939-40, p. 751; also the
discussion in Proceedings of the Royal Society of Medicine, vol. 37, 1943-4, P- : 94-
38 Report of the Inter-Departmental Committee on Medical Schools (Goodenough Report),
London, HMSO, 1944.
39 Ibid, p. 167.
40 Ibid, pp. 169-70.
41 M. Foucault, Discipline and punish: the birth ofthe prison, London, Alien Lane, 1977,
P. 209.
42 F.A.E Crewe, 'Social medicine: an academic discipline and an instrument of
social policy', Lancet, vol. B, 1944, p. 618.
43 Ibid-
44 W.Jameson, 'War and the advancement of social medicine', Lancet, vol. 2, 1942,
P- 479-
45 Ibid.
Chapter 5
i W.P.D. Logan & E.M. Brooke, Survey of Sickness, 1943-52, London, HMSO,
1957, pp. 1-4. (These milestones of survey research were selected by Logan &
Notes 125
Brooke for their preliminary 'history' of survey techniques. Such histories, in
tending to suggest the wisdom that follows, inevitably document progressive
enlightenment.)
2 M. Foucault, Discipline and punish: the birth of the prison, London, Alien Lane,
'977-
3 Ibid.
4 T. Lewis, 'Research in medicine: its position and its needs', British Medical
Journal, vol. I, 1930, p. 479.
5 Ibid, p. 481.
6 Ibid, p. 480.
7 T. Lewis, 'Harveian oration on clinical science', British Medical Journal, vol. 2,
1933, P- 720-
8 Ibid.
9 T.I. Bennett & J.A. Ryle, 'Normal gastric function', Guy's Hospital Reports, vol.
71, 1921, p. 286.
10 J.A. Ryle, Changing disciplines, London, Oxford University Press, 1948, p. 70.
11 A.K. Shapiro, 'A contribution to a history of the placebo effect', Behavioural
Science, vol. 5, 1960, p. 109.
12 Ibid.
13 Editorial, 'Amateur medical statisticians', Lancet, vol. i, 1943, p. 19.
14 Editorial, 'Patulin disappoints', Lancet, vol. 2, 1944, p. 380.
15 As judged by A. Cochrane, 'The random controlled trial', Lancet, vol. i, 1972,
P- 985-
16 Medical Research Council, 'Streptomycin treatment of tuberculous meningitis',
Lancet, vol. i, 1948, p. 582.
17 Medical Research Council, 'Streptomycin treatment of pulmonary tuberculo-
sis', British Medical Journal, vol. 2, 1948, p. 769.
18 Editorial, 'The controlled therapeutic trial', British Medical Journal, vol. 2, 1948,
P- 796.
19 Editorial, 'Streptomycin in pulmonary tuberculosis', Lancet, vol. 2, 1948,
P- 733-
20 This section draws on a previous paper: D. Armstrong, 'Clinical sense and
clinical science', Social Science and Medicine, vol. n, 1977, p. 599.
21 Editorial, 'Mathematics and medicine', Lancet, vol. i, 1937, p. 31.
22 A.B. Hill, Principles of medical statistics, London, The Lancet, 1937.
23 M. Greenwood & W.W.C. Topley, 'Experimental epidemiology: some general
considerations', Proceedings of the Royal Society of Medicine, vol. 19, 1925-6, p. 31.
24 Ibid.
25 See, for example, W. Hamer, 'The crux of epidemiology', Proceedings of the Royal
Society of Medicine, vol. 24, 1930 1, p. 1425.
26 J.E. Lane-Clayton, A further report on cancer of the breast with special reference to its
associated antecedent conditions, London, HMSO, 1926.
27 R. Doll & A.N. Hill, 'Smoking and cancer of the lung', British Medical Journal,
vol. 2, 1950, p. 739.
28 W. Pickles, 'Epidemiology in country practice', Proceedings of the Royal Society of
Medicine, vol. 28, 1934-5, P- '337-
126 Notes
29 B.E. Spear & C.A. Gould 'Mechanical tabulation of hospital records',
Proceedings of the Royal Society of MedicM, vol. 30, 1936-7, p. 633.
30 J.A. Ryle, Changing disciplines.
31 P. Stocks, 'The measurement of morbidity', Proceedings of the Royal Society of
Medicine, vol. 37, 1943-4, p. 59.
33 Ibid.
34 W.P.D. Logan & E.M. Brooke, Survey of Sickness.
35 Annual report of the Chief Medical Officer, On the state of the public health,
London, Ministry of Health, 1920, p. 137.
36 Ibid (1924).
37 7Airf(i93i).
38 /«rf(i 935).
39 Ibid.
40 See chapter 4 of this book.
41 T. Jeffery, 'Mass Observation', paper presented to Annual Conference of the
Society for the Social History of Medicine, 1980.
42 W. Langdon-Brown, quoted at conference on 'The social environment and the
war', Lancet, vol. i, 1940, p. 285.
43 K. Box & G. Thomas, 'The War-time Social Survey', Journal of the Royal
Statistical Society, vol. 107, 1944, p. 151.
44 Details reported in Lancet, vol. 2, 1940, p. 144.
45 Ibid.
46 K. Box & G. Thomas, 'War-time Social Survey', p. 151.
47 Editorial, 'Results of the War-time Social Survey', Lancet, vol. 2, 1940, p. 305.
48 Report of the Chief Medical OffiCER, On the state of the public health during sixyears
of war, London, HMSO, 1946, p. 118.
49 Ibid.
51 D. MacKay, Hospital morbidity statistics. Studies on Medical and Population
Subjects, no. 4, London, HMSO, 1951.
52 Reported in W.P.D. Logan & E.M. Brooke, Survey of Sickness, p. 12.
53 Editorial, 'A health survey', Lancet, vol. i, 1944, p. 829.
54 P. Stocks, The measurement of morbidity.
55 J.A. Ryle, Changing disciplines, pp. 79-81.
56 J.A. Ryle, Changing disciplines, p. 82.
59 K. Box & G. Thomas, 'War-time Social Survey', pp. 55-64.
60 J.A. Ryle, Changing disciplines, pp. 55-64.
61 C. Gordon (ed.), Michel Foucault: power!knowledge, Brighton, Harvester, 1980.
63 Editorial, 'Sample surveys', Lancet, vol. 2, 1950, p. 22.
64 M. Foucault, Discipline and punish: the birth of the prison, London, Alien Lane,
'977-
65 J.A. Ryle, Changing disciplines, p. 64.
Notes 12 7
Chapter 6
1 The various sociological analyses of the medical profession, which have emerged
in the post-war years, from functionalist to Marxist, can all be seen to have
struggled with the relationship between the profession and power though even at
its most explicit the role of power has been subsidiary. See, for example, TJ.
Johnson, Professions and power, London, Macmillan, 1972.
2 R. Sievens, Medical practice in modem England: the impact of specialisation and state
medicine, New Haven, Yale, 1966; R. Bucher & A. Strauss, 'Professions in
process', American Journal of Sociology, vol. 66, 1961, p. 325.
3 Cohen, for example, suggested that during the last few decades 'speialities have
arisen which are based on vastly diverse criteria': H. Cohen, 'Reflections on
specialisation in medicine', Annals of the Royal College of Surgeons, vol. 27, 1960
p. i.
5 This chapter is partly based on D. Armstrong, 'Child development and medical
ontology', Social Science and Medicine, vol. 13, 1979, p. 9.
6 Various textbooks on diseases of children had been published; at Great
Ormond Street a Hospital for Sick Children had been opened. See chapter 2 of
this book.
7 D. Forsyth, Children in health and disease, London, John Murray, 1909, p. 271.
8 R. Hutchison, 'Paediatrics, present and prospective', Lancet, vol. 2, 1940, p. 799.
10 Archives of Disease in Childhood, founded in 1924, was the journal of the British
Paediatric Association.
11 D. Jameson, 'Effects of war-time rationing on child health', Proceedings of the
Royal Society of Medicine, vol. 35, 1941 2, p. 273.
12 Quoted at meeting of Section for Study of Disease in Childhood on 'School
medical services - present and future', Proceedings of the Royal Society of Medicine,
vol. 38, i944-5> P- 373-
13 Discussions published in Proceedings of the Royal Society of Medicine, 1939-45.
14 Discussion on 'Effects of war-time rationing on child health', Proceedings of the
Royal Society of Medicine, vol. 35, 1941-2, p. 273.
15 Discussion on 'Nutritional anaemia in children and women: a war-time
problem', Proceedings of the Royal Society of Medicine, vol. 36, 1942-3, p. 69.
16 Ibid.
17 Reported in discussion on 'Decline in breast feeding', Proceedings of the Royal
Society of Medicine, vol. 36, 1942-3, p. 382.
18 'Nutritional survey of school children in Oxfordshire, London and Birming-
ham', Proceedings of the Royal Society of Medicine, vol. 37, 1943-4, p. 313.
19 Reported at British Paediatric Association AGM, Archives of Disease in Childhood,
vol. 24, 1949. See note 25.
20 G.M. Alien-Williams, 'Some observations on the growth of children', Archives of
Disease in Childhood, vol. 21, 1946, p. 190.
21 R.W.P. Ellis, 'Height and weight in relation to onset of puberty in boys', Archives
of Disease in Childhood, vol. 21, 1946, p. 181.
128 Notes
22 C. Asher, 'The relationship of birth weight to mental development', Archives of
23 F. Faulkner, 'Measurement in growth and development studies', Archives of
24 R.C. MacKeith, 'Measurement and the paediatrician', Developmental Medicine
and Child Neurology, vol. 6, 1964, p. 453.
25 The MRC Survey under Douglas took its cohort from 1948. Early results were
published in the 19503, the results of the Ministry of Health Survey in 1959:
Standards of Normal H'eight in Infancy. Reports on Public Health and Medical
Subjects, no. 99, London, HMSO, 1959.
26 E.R. Bransby, quoted in the 'Report of the Height and Weight Survey
Sub-Committee of the British Paediatric Association', Archives of Disease in
Childhood, vol. 19, 1944, p. 37.
27 E.R. Brandsby & VV.H. Hammon, 'Growth and development standards and
their clinical application', Proceedings of the Royal Society of Medicine, vol. 43, 1950,
p. 825.
28 J.M. Tanner, ibid, p. 824.
29 J.W.B. Douglas, ibid, p. 828.
30 R.S. Illingworth, The normal child, London, Churchill, 1953.
31 Ibid (2nd edn: 1957), p. v.
32 Ibid. (3rd edn: 1964), p. 196.
33 J. Apley, 'Paediatrics and the undergraduate curriculum', Lancet, vol. 2, 1965,
P- 6 33-
34 Editorial, 'Growth in childhood', British Medical Journal, vol. i, 1957, p. 1232.
35 Editorial, 'Environment and heredity', BritishMedicaljoumal, vol. i, 1950^.887.
36 Editorial, 'The growth and development of children', British Medicaljoumal, vol.
i, '95 2 > P- 963-
37 Reported at the British Paediatric Association AGM, Archives of Disease in
Childhood, vol. 18, 1943, p. 54.
38 'Report of Child Psychology Sub-Committee of the British Paediatric Associa-
tion', Archives of Disease in Childhood, vol. 22, 1946, p. 57.
39 Reported in Archives of Disease in Childhood, vol. 23, 1948, p. 141.
40 Particularly, A. Gesell et al., Biographies of child development: the mental growth and
careers of 84 infants and children, London, Hamish Hamilton, 1939.
41 For history see A. Gesell, Infant behaviour: its genesis and growth, New York,
McGraw-Hill, 1934.
42 A. Gesell et al., Biographies of child development.
43 For details see A. Gesell, Infant and child in the culture of today: the guidance of
development in home and nursery school, London, Hamish Hamilton, 1943.
44 A. Gesell, The pre-school child from the standpoint of public hygiene and education,
Cambridge, Mass., 1923.
45 A. Gesell et al., Biographies of child development, p. 309.
46 A.W. Franklin, 'Paediatrics 1984', Lancet, vol. I, 1965, p. 117.
47 Ibid.
48 B. Corner, 'Progress in perinatal paediatrics', Proceedings of the Royal Society of
Medicine, vol. 57, 1964, p. 231.
Notes 129
49 N.B. Capon, 'The training of clinical teachers', Proceedings of the Royal Society of
Medicine, vol. 39, 1945 6, p. 65.
50 Editorial, 'More paediatric planning', Lancet, vol. 2, 1942, p. 370.
51 G.B. Fleming, 'Why not an adolescents' hospital?', Lancet, vol. I, 1942, p. 631.
52 P. Catzel, 'Paediatrics', British Medical Journal, vol. 2, 1955, p. 1028.
53 J. Apley, 'Paediatrics and the undergraduate curriculum'.
54 R.G. Mitchell, 'The community paediatrician', British Medical Journal, vol. 2,
1971, P- 95-
55 R.G. Mitchell, 'The child, science and society', Lancet, vol. i, 1964, p. 181.
56 'Report of the Executive Committee of the British Paediatric Association',
Archives of Disease in Childhood, vol. 35, 1960, p. 412.
57 'Report of the Nursing Committee of the British Paediatric Association',
Archives of Disease in Childhood, vol. 40, 1965, p. 448.
58 R.G. Mitchell, 'The child, science and society'.
59 Report of the Committee on Child Health Services, Fit for the future, London,
HMSO, 1976.
60 S.D.M. Court & A. Jackson, Paediatrics in the seventies, London, Nuffield
Provincial Hospitals Trust, 1972.
61 Report of the Committee on Child Health Services.
62 A.W. Franklin, 'Paediatrics 1984'.
63 J. Apley, 'Paediatrics and the undergraduate curriculum'.
64 S.D.M. Court, 'Child health in a changing community', British Medical Journal,
vol. I, 1971, p. 125.
65 M.A. Salmon, 'Developmental paediatrics', Lancet, vol. i, 1972, p. 379.
66 N.B. Capon, 'Development and behaviour of children', British Medical Journal,
vol. i, 1950, p. 859.
67 R.S. Illingworth, The normal child, preface.
68 Ibid, p. 89.
69 Ibid, p. 216.
Chapter 7
1 Report of the Mental Deficiency Committee, London, HMSO, 1929; see p. 2 for a
description of the history of the report.
2 Ibid, p. i.
3 Ibid, p. 3.
4 Mid, p. 3.
5 E.O. Lewis, Report on an investigation into the incidence of mental deficiency in six areas,
it)2!)-ig2j, London, HMSO, 1929.
6 The Mental Deficiency Act of 1913 required all mentally defective children to be
known; the Elementary Education (Defective and Epileptic Children) Act of
1914 further required that they should receive appropriate education.
7 E.O. Lewis, Mental deficiency, p. 22.
8 P. Lemkau et al., 'A survey of statistical studies on the prevalence and incidence
of mental disorder in sample populations', Public Health Reports, vol. 58, 1943,
P- 1909-
130 Notes
9 E. Slater, 'The incidence of mental disorder', Annals of Eugenics, vol. 6, 1934-5,
p. 172.
10 E. Slater, 'A demographic study of a psychopathic population', Annals of
Eugenics, vol. 12, 1943-5, p. 121.
11 W. Mayer-Gross, 'Mental health survey in a rural area: a preliminary report',
Eugenics Review, vol. 40, 1948 9, p. 141.
12 Ibid, p. 140.
13 Ibid.
14 E. Glover, 'The birth of social psychiatry', Lancet, vol. 2, 1940, p. 239.
15 Ibid.
16 H. Devine, Recent advances in psychiatry, London, Churchill, 1929.
17 Editorial, 'The prognosis of schizophrenia', Lancet, vol. i, 1938, p. 384.
18 Editorial, 'Insulin in schizophrenia', Lancet, vol. i, 1936, p. 1418.
19 A.T. Scull, Decarceration: community treatment and the deviant, Englewood Cliffs,
Prentice-Hall, 1977.
20 See, for example, K.Jones, A history of the mental health services, London, Routledge
and Kegan Paul, 1972.
21 Editorial, 'The psychiatric day hospital', Lancet, vol. I, 1955, p. 442.
22 Editorial, 'Visiting in mental hospitals', Lancet, vol. I, 1956, p. 334.
23 Editorial, 'Walls of Jericho', Lancet, vol. i, 1957. p. 1177.
24 M. Culpin, 'Psychology in medicine', Lancet, vol. 2, 1945, p. 519.
25 F.M.R. Walshe, Diseases of the nervous system, London, Edinburgh, Livingstone,
1908.
26 Editorial, 'Brain and mind', Lancet, vol. 2, 1947. p. 357.
27 W.R. Brain, Diseases of the nervous system, London, Oxford University Press,
1933-
28 Editorial, 'The biological approach to mental disorder', Lancet, vol. i, 1941,
p. 544.
29 H.M. Flanagan, Tn the mental hospital', Lancet, vol. 2, 1955, p. 1295.
30 H. Merskey & W.L. Tonge, Psychiatric illness, London, Bailliere Tindall, 1965,
P- 15-
31 J.G. Howells, Nosology of psychiatry, London, Society of Clinical Psychiatrists,
1970.
32 S. Crown, Essential principles of psychiatry, London, Pitman, 1970.
33 M. Hamilton (ed.), Fish's clinicalpsychopathology, Bristol, John Wright, 1974.
34 W.H. Trethowen, Psychiatry, London, Bailliere Tindall, 1979, p. 97.
35 Memorandum on the Future Organisation of Psychiatric Services, Jointly produced by
the Royal College of Physicians, the BMA group of practitioners of psychologic-
al medicine and the Royal Medico-Psychological Association, 1945.
36 F. Fish, 'Psychiatry as a medical specialty', Lancet, vol. i, 1965, p. 565.
37 See, for example, L. Srole et al., Mental health in the metropolis: the midtown study,
New York, McGraw-Hill, 1962; and D.C. Leighton et al., The character of danger,
New York, Free Press, 1963.
38 E.J.R. Primrose, Psychological illness: a community study, London, Tavistock,
1962; G.W. Brown & T. Harris, Social origins of depression, London, Tavistock,
1979-
Notes 131
40 See, for example, M. Balint, The doctor, his patient and the illness, London, Pitman,
'957-
41 R.F. Tredgold, 'The integration of psychiatric teaching in the curriculum',
Lancet, vol. i, 1962, p. 1345.
42 F. Fish, 'Psychiatry as a medical specialty', p. 567.
43 R.F. Tredgold, 'The integration of psychiatric teaching'
44 Editorial, 'Teaching psychiatry', Lancet, vol. i, 1961, p. 814.
45 Royal Commission on Medical Education, London, HMSO, 1968.
46 D.K. Henderson & R.D. Gillespie, A textbook of psychiatry, London, Oxford
University Press, 1944 (6th edn).
47 T.S. Clouston, Unsoundness of mind, London, Methuen, 1911, p. 322.
48 J.A. Ross, The common neuroses, London, Edward Arnold, 1923.
49 I. Skottowe, 'Psychological medicine: current methods of treatment', Lancet, vol.
1. 1944, P- 329-
50 M.Jones & R.N. Rapoport, 'Administrative and social psychiatry', Lancet, vol.
2. I955> P- 386.
51 D.H. Clark, 'Administrative therapy', Lancet, vol. i, 1958, p. 805.
52 J.A.R. Bickford, 'The forgotten patient', Lancet, vol. 2, 1955, p. 969.
53 D.V. Martin, 'Institutionalisation', Lancet, vol. 2, 1955, p. 1188. There is also the
large sociological literature. See especially E. GofTman, Asylums: essays on the social
situation of mental patients and other in-mates, London, Penguin, 1961.
54 A. Lewis, 'Between guesswork and certainty in psychiatry', Lancet, vol. i, 1958,
P- '73-
55 D.R. MacCalman, 'The development of psychiatry within the NHS', Proceedings
of the Royal Society of Medicine, vol. 42, 1949, p. 365.
56 D. Curran, 'Psychiatry united', Proceedings of the Royal Society of Medicine, vol. 45,
1951-2, p. 105.
57 See, for example, T. Szasz, The myth of mental illness, London, Paladin, 1961;
R. Boyers & R. Orrill, Laing and anti-psychiatry, London, Penguin, 1972.
58 S. Crown, 'Essential principles of psychiatry', p. 19.
59 R.F. Tredgold, 'The integration of psychiatric teaching'
60 W.H. Trethowen, Psychiatry, p. 54.
61 Ibid, p. 52.
62 D. Curran, M. Partridge & P. Storey, Psychological medicine, London, Churchill
Livingstone, 1972, p. 68 also R.E. Kendell, The role of diagnosis in psychiatry,
Oxford, Blackwell, 1975.
63 M. Bleuler, quoted in D. Hill, 'The bridge between neurology and psychiatry',
Lancet, vol. I, 1964, p. 513.
64 Jasper's Generalpsychopathology was translated by Hamilton, published in 1963,
and proved influential. See, for example, F.K. Taylor, Psychopathology: its causes
and symptoms, London, 1966; or D. Bannister, 'Repertory grid technique', British
Journal of Psychiatry, vol. 3, 1965, p. 977.
65 D. Curran et al. Psychological medicine (5th edn onwards).
66 H. Merskey & W.L. Tonge, Psychiatric illness, p. 21.
67 Ibid, p. 6.
132 Notes
Chapter 8
1 M. Foucault, Discipline and punish: the birth ofthe prison, London, Alien Lane, 1977,
see part HI; also chapter i of this book.
2 R. Pinker, English hospital statistics: 1861-1938, London, Heinemann, 1966.
3 Editorial, 'The renaissance of general practice', Lancet, vol. 2, 1929, p. 933.
4 A.G. Signy, 'Trends in clinical pathologists', Journal of Clinical Pathology, vol. 23,
197°. P- 744-
5 Editorial, 'Clinical specialism', Lancet, vol. 2, 1945, p. 209.
6 B. Moynihan, reported under 'Medical news', Lancet, vol. 2, 1929, p. 957.
7 Editorial, 'General practitioners and hospitals', British Medical Journal, vol. 2,
'949> P- 'OS 1 -
8 O.R. Tisdall, 'The general practitioner and scientific thought', British Medical
Journal, vol. i, 1941, p. 722.
9 H. Crichton-Miller, 'Training of the general practitioner', Lancet, vol. 2, 1945,
p. 231.
10 Editorial 'Research in general practice', Lancet, vol. 2, 1926, p. 863.
11 Ibid.
12 C. Lindsay, 'The profession and the public', British Medical Journal, vol. 2, 1938,
p. 163-
13 H.H. Sanguinetti, 'A general practitioner service', British Medical Journal, vol. i,
'942, P- 25.
14 Lancet, Editorial, 'Research in general practice'.
15 See, for an overview, R.J.F.H. Pinsent, 'James MacKenzie and research
tomorrow', Journal of the College of General Practitioners, vol. 190, 1963, p. 114.
16 W. Pickles, Epidemiology in a country practice, Bristol, Wright, 1939.
17 W. Pickles, 'Epidemiology in the Yorkshire Dales', Practitioner, vol. 74, 1955,
p. 76.
18 Pointed out by F. Honigsbaum, The division in British medicine, London, Frank
Page, 1979.
19 Editorial, 'Psychotherapy in general practice', Lancet, vol. i, 1939, p. 707.
20 C. Lindsay, 'The profession and the public', p. 164.
21 Editorial, 'The Presidential address', British Medical Journal, vol. 2, 1938,
p. 183.
22 P. Stocks, Sickness in the population of England and Wales: 1844-47, London, HMSO,
1949-
23 J. Pemberton, 'Illness in general practice', British Medical Journal, vol. i, 1949,
p. 306.
24 R.M. McGregor, 'The work of a family doctor', Edinburgh Medical Journal, vol.
57, 1950, p. 433.
25 J. Fry, 'A year of general practice: a study in morbidity', British Medical Journal,
vol. 2, 1952, p. 429.
26 T.S. Kuhn, The structure of scientific revolutions, Chicago University Press, 1962.
27 J. Fry, 'A year of general practice'
28 Logan, W.P.D. General practitioner's records: an analysis of the clinical records of 8
practices during the period April igî-March 1952, London, HMSO, 1953.
Notes 133
29 Measurement of morbidity, London, HMSO, 1954.

30 W.P.D. Logan & E.M. Brooke, The survey of Sickness, 1943-52, London, HMSO,
'957-
31 W.P.D. Logan & A. A. Cushion, Morbidity statistics from general practice, vol. i,
London, HMSO, 1958.
32 Editorial, 'The Morbidity Survey - and after', Journal of the College of General
Practitioners, vol. 2, 1959, p. 2.
33 Ibid, p.3.
34 The College set up a Research Committee and started publishing a Research
Newsletter in 1953. An 'Epidemic Observation Scheme' was started in 1954.
35 College Research Committee, 'The continuing observation and recording of
morbidity', Journal of the College of General Practitioners, vol. I, 1958, p. 107.
36 S.E. England Faculty, 'Report on epidemic winter vomiting', College of General
Practitioners' Research Newsletter, no. 8, 1955, p. 96.
37 S.W. England Faculty, 'Report on obstetric survey', College of General Practition
ers' Research Newsletter, no. 10, 1956, p. 24.
38 Yorkshire Faculty, 'Report on survey of unrecorded cases of cancer', College of
General Practitioners' Research Newsletter, no. 13, 1956, p. 183.
39 B. Finlay et al., 'Stress and distress in general practice', Practitioner, vol. 172,
1954, p. 183.
40 J. Horder & E. Horder, 'Illness in general practice', Practitioner, vol. 173, 1954,
p. 177.
41 J. Fry, 'Five years of general practice: a study in simple epidemiology', British
42 E.M. Backett et al., 'Studies of general practice', Proceedings of the Royal Society of
Medicine, vol. 46, 1953, p. 707.
43 D.L. Crombie, 'Prevalence of psychogenic illness in general practice', College of
General Practitioners'Research Newsletter, no. 16, 1957, p. 218.
44 R.N. Theakston, 'A social survey in a country practice', College of General
45 R.P.C. Handfield-Jones, 'One year's work in a country practice', Journal of the
College of General Practitioners, vol. 2, 1959, p. 323.
46 J.G. Bancroft & C.A.H. Watts, 'A survey of patients with chronic illness in
general practice', Journal of the College of General Practitioners, vol. 2, 1959, p. 338.
47 D.L. Crombie, 'A casualty survey', Journal of the College of General Practitioners,
vol. 2, 1959, p. 346.
48 C.A.H. Watts, 'The GP and research', Journal of the College of General Practitioners,
vol. i, suppl., 1958, p. 37.
49 Ibid, p. 39.
50 There is no necessary congruence between the levels of discourse, effects and
practices, as Gordon has pointed out: C. Gordon (ed.), Michel Foucault:
power/know ledge, Brighton, Harvester, 1980.
51 General practice and the training of the general practitioner, British Medical Associa-
tion, 1950.
52 Report of the General Practice Steering Committee, 'A college of general
practitioners', British Medical Journal, vol. 2, 1952, p. 1321.
134 Notes
53 C.R.G. Howard, 'The problem of defining the extent of morbidity in general
pactice', Journal of the College of General Practitioners, vol. 2, 1959, p. 119.
54 R.J.F.H. Pinsent, 'Research in general practice', Journal of the College of General
Practitioners, vol. i, 1958, p. 23.
55 M. Marcus, 'The patient as a whole person. The problem of stress in general
practice', Journal of the College of General Practitioners, vol. 1, suppl. no. 2, 1958,
p. 26.
56 See for example, I. Pirrie, 'The GP at the crossroads', British MedicalJournal, vol.
2, 1950, p. 169 L.Johnston, 'Preparing for general practice', Lancet, vol. 2, 1950,
p. 824; W.M.E. Anderson, 'The GP at the crossroads', British Medical Journal,
vol. i, 1950, p. 1437.
In a previous paper I ascribed the emergence of complaints about trivia to a
concern about the low status of the GP's work vis-a-vis that of hospital medicine
without recognising that these complaints belonged to a general discourse on
trivia, both 'negative' and 'positive', which emerged at this time: D. Armstrong,
'The emancipation of biographical medicine', Social Science and Medicine, vol. 13,
'979, P- '
57 M. Lask, 'The GP at the crossroads', British MedicalJournal, vol. i, 1950, p. 902.
58 L.Johnston, 'Preparing for general practice'.
59 Editorial, 'Diagnosis and nosology of minor maladies', College of General
60 See for example, J. Fry, 'A year of general practice'.
61 Suggested by the Statistics Sub-Committee of the Registrar-General's Advisory
Committee on Medical Nomenclature and Statistics, Measurement of morbidity.
62 Pointed out as a problem, for example, by C.R.G. Howard, 'Defining the extent
of morbidity', p. 122.
63 J. Horder & E. Horder, 'Illness in general practice', p. 184.
64 E.M. Backett et al., 'Studies of general practice'.
65 See, for example, D. Mechanic & E.H. Volkart, 'Illness behaviour and
medical diagnoses', Journal of Health and Human Behaviour, vol. i, 1960, p. 86;
and D. Mechanic, 'The concept of illness behaviour', Journal ofChronic Diseases,
vol. 15, 1962, p. 189.
66 See, for example, M.EJ. Wadsworth et al., Health and sickness: The choice of
treatment, London, Tavistock, 1971.
67 See, for example, the early writings on the 'validity' of patients' symptoms,
either in terms of their identification or in terms of external medical referrents,
e.g., D. Mechanic & M. Newton, 'Some problems in the analysis of morbidity
data', Journal of Chronic Disease, vol. 18, 1965, p. 569; and E.A. Suchman &
B.S. Phillips, 'An analysis of the validity of health questionaires', Social Forces,
vol. 36, 1958, p. 223.
The disappearance of these methodological issues takes place when, in the late
19705, the whole field of illness behaviour is removed from the centre of medical
sociologists' research interests. A workshop at the Annual Conference of the
Medical Sociology Group in 1976, was on the question: 'Whatever happened to
illness behaviour?'
Notes 135
68 All quotations taken from Discussion: 'What is general practice?', Proceedings of
the Royal Society of Medicine, vol. 44, 1951, p. 113.
69 C.A.H. Watts, 'The GP and research'.
70 D. O'Neill, 'Stress problems in general practice', Journal of the College of General
Practitioners, vol. i, suppl. no. 2, 1958, p. 7.
71 M. Marcus, 'The patient as a whole person', ibid, p. 10.
72 See for example, J.H. Hunt, 'The scope and development of general practice in
relation to other branches of medicine', Lancet, vol. 2, 1955, p. 681; or L.W.
Batten, 'The essence of general practice', Lancet, vol. 2, 1956, p. 365.
73 J.H. Hunt, 'The scope and development of general practice'.
74 See, for example, P. Hopkins, 'Psychotherapy in general practice', Lancet, vol. 2,
1955, p. 455 C.A.H. Watts, Neuroses in general practice, London, Constable, 1956;
H.S. Pasmore, 'Psychiatry in general practice', Lancet, vol. i, 1958, p. 524
C.A.H. Watts, 'Management of chronic psychoneurosis in general practice',
Lancet, vol. 2, 1958, p. 362.
75 M. Balint, 'The doctor, his patient and the illness', Lancet, vol. i, p. 683, 1955,
later published as book with same title: London, Pitman, 1956.
76 Ibid.
77 J. Horder, 'The role of the GP in psychological medicine', Proceedings of the Royal
Society of Medicine, vol. 60, 1967, p. 264.
78 Consultative Council on Medical and Allied Services, Interim report on the future
provision ofmedical and allied services (Dawson Report), London, HMSO, 1920; see
also chapter 4 of this book.
79 'It shall be the duty of every local authority to provide, equip and maintain to the
satisfaction of the Minister premises which shall be called health centres.'
Section 21, National Health Service Act, London, HMSO, 1946.
80 H.W. Ashworth, 'The failure of health centres', Journal of the College of General
Practitioners, vol. 2 1959, p. 357.
81 For an account of this period, see, J.G. Beales, Sick health centres, London,
Pitman, 1978, pp. 13-14.
82 Ibid.
83 Ten health centres were in existence before the NHS. 23 were opened in the
years 1948-65 60 were opened during 1966-8: M. Clarke, 'Health centres: an
evaluation of past and present developments', Update, vol. 5, 1972, p. 1185.
A renewed interest in health centres can be identified from the late 19505
onwards, e.g., H.W. Ashworth, 'The failure of health centres'; Editorial, 'Health
centres or medical centres?', Lancet, vol. i, 1961, p. 149.
84 J.R. Edwards, 'A survey of health centres in the south-wesf, Update publications,
1972. Reported in D. Hicks, Primary health care, London, HMSO, 1976.
85 For an overview see C. Watson & M. Clarke, 'Attachment schemes and
development of the health care team', Update, vol. 5, 1972, p. 489.
86 Report of the Sub-Committee of the Standing Medical Advisory Committee,
CHSC, The field of work of the family doctor, London, HMSO, 1963 (Gillie
Report).
87 C. Watson & M. Clarke, 'Health centres'
88 Gillie Report.
136 Notes
89 'The family doctor service: a Charter from the BMA', Lancet, vol. i, 1965,
P- 594-
go M. Drury, 'Work-load and the general practitioner', Lancet, vol. 2, 1967, p. 823.
91 J. Fry, 'Administration and the general practitioner', Lancet, vol. 2, 1967,
P- "93-
92 Ibid.
Chapter g
1 For history, see, for example, J.H. Howell, A student's guide to geriatrics, London,
Staples Press, 1963, chapter i.
2 J.H. Sheldon, The social medicine of old age, Oxford, Nuffield, 1948.
3 B. Seebohm Rowntree, Old people: a report of the Survey Committee on the problem of
ageing and the care of old people, Oxford, Nuffield, 1947.
4 J.H. Sheldon, 'Some aspects of old age', Lancet, vol. i, 1948, p. 621.
5 J.H. Sheldon, 'The social medicine of old age', p. 8.
6 Ibid.
7 W. Hobson & J. Pemberton, The health of the elderly at home, London, Butterworth,
'955-
8 A. P. Thompson et al., The care of the ageing and chronic sick, Edinburgh,
Livingstone, 1951.
9 T. Ferguson, 'Aged sick nursed at home', Lancet, vol. i, 1948, p. 417.
10 W. Hobson, 'General problems of ageing', in W. Hobson (ed.), Modern trends in
geriatrics, London, Butterworth, 1956, p. 17.
11 J.H. Sheldon, quoted in Report of the yd Congress of the International Association of
Gerontology, London, Edinburgh, Livingstone, 1954, p. 340.
12 J. Agate, The practice of geriatrics, London, Heinemann, 1963, p. 12.
13 T.H. Howell, A student's guide to geriatrics, p. 19.
14 T.H. Howell, Oldage: some practical points in geriatrics, London, Lewis, 1975,p. 11.
15 Ibid, p. 165.
16 See, for example, J.C. Brocklehurst, A textbook ofgeriatric medicine and gerontology,
London, Churchill Livingstone, 1973.
17 J.C. Brocklehurst, 'The elderly sick', Lancet, vol. 2, 1971, p. 657.
18 For a more detailed analysis see W.R. Arney & B.J. Bergen, 'The anomaly, the
chronic patient and the play of medical power', Sociology of Health and Illness,
forthcoming.
19 See, for example, N. Coni et al., Lecture notes on geriatrics, Oxford, Blackwell, 1977,
P . 6.
20 F. Anderson, Practical management of the elderly, Oxford, Blackwell, 1967, p. 81.
21 Ibid, p. 403.
22 Ibid, p. 55.
23 G.R. Andrews et al., The 'practice of geriatric medicine in the community', in
G. McLachlan (ed.), Problems and progress in medical care, $th series, London,
Nuffield, 1971.
Tavistock, 1963, pp. 16-20.
Notes 137
25 Ibid, p. 17.
26 J- Agate, The practice of geriatrics, p. 552.
27 See, for example, F. Anderson, Practical management of the elderly, chapter 24.
28 This tension between home and hospital is also apparent in the care of the dying:
the recent 'hospice movement', for example, in a sense offers a medicalised space
yet a natural death. See my earlier paper, D. Armstrong, 'Pathological life and
death: medical spatialisation and geriatrics', Social Science and Medicine, vol. 15,
1981, p. 253. Much of the following section on the problem of the normal in
geriatrics is drawn from it.
29 J. Agate, The practice of geriatrics, p. 40.
30 I. Felstein, Later life; geriatrics today and tomorrow, London, Penguin, 1969,
p. 24.
31 F.I. Caird & T.G. Judge, Assessment of the elderly, London, Pitman, 1974, p. vii.
32 W. Hobson & J. Pemberton, The health of the elderly at home, pp. 23, 194.
33 A. Jordan, 'Normal values and the interpretation of biochemical data in the
elderly', in W. Hobson, (ed.), Modern trends in geriatrics.
34 Ibid.
35 N. Coni et al., Lecture notes in geriatrics, p. 88.
36 S.C.D. Cayley, 'Care of the elderly', Lancet, vol. I, 1976, p. 912.
37 B. Lush, 'The scope of research in geriatric medicine', Age and Ageing, vol. 3,
'974. P- 2.
38 M.K. Thompson, 'Can geriatrics survive?', British Medical Journal, vol. I, 1976,
P- '590-
39 B. Lush, 'The scope of research in geriatric medicine'.
40 'One foot is the basic science or sciences that comprise gerontology and the other
foot is clinical experience drawn from medicine in general.': R.I.S. Bayliss,
'Geriatrics and medical education', in J. Agate (ed), Medicine in old age, London,
Pitman, 1966.
41 A.N. Exton-Smith, Medical problems of old age, Bristol, John Wright, 1955.
42 Ibid.
43 J- Agate, 'The practice of geriatrics', p. u.
44 B. Isaacs, An introduction to geriatrics, London, Bailliere Tindall, 1965.
45 R.E. Tunbridge, 'Senescence, health and disease', in J. Agate (ed), Medicine in
old age.
46 F. Anderson, Practical management of the elderly, p. i.
47 Ibid, p. 20.
48 W.F. Anderson, 'Normal and abnormal ageing', in W.F. Anderson & B. Isaacs
(eds), Current achievements in geriatrics, London, Cassell, 1964.
49 W.F. Anderson, Practical management of the elderly, p. 20.
50 N. Coni et al., Lecture notes in geriatrics, p. 88.
51 G. Adams, Essentials ofgeriatric medicine, London, Oxford University Press, 1977,
P . 2.
52 J.H. Sheldon, 'Some aspects of old age'.
53 Lord Amulree, quoted in Editorial, 'Old and ailing', Lancet, vol. i, 1947. p. 105.
54 B. Isaacs, 'Has geriatrics advanced?', in B. Isaacs (ed.), Recent advances in
geriatrics, London, Churchill Livingstone, 1978. p. 2.
138 Notes
Chapter 10
1 Report of the Inter-Departmental Committee on Medical Schools (Ch., Goodenough),
London, HMSO, 1944.
2 J.N. Morris, Uses of epidemiology, Edinburgh, Livingstone, 1957.
3 Ibid, p. 3.
4 Ibid, p. 40.
5 J.N. Morris, 'A medical examination of 1592 workers', Lancet, vol. I, 1941^.51.
6 Medical Research Council, Haemoglobin levels in Great Britain in 1943, MRC
Special Report no. 252, London, HMSO, 1945.
7 H.E. Magee & E.H.M. Milligan, 'Haemoglobin levels before and after labour',
British Medical Journal, vol. 2, 1951, p. 1307.
8 W.T.C. Berry & H.E. Magee, 'Haemoglobin levels in adults and children',
British Medical Journal, vol. I, 1952, P. 410.
9 A.L. Cochrane et al., 'Pulmonary tuberculosis in the Rhondda Fach: an interim
report of a survey of a mining community', British Medical Journal, vol. 2, 1952,
P- 843-
10 I.T.T. Higgins et al., 'Respiratory symptoms and pulmonary disability in an
industrial town: survey of a random sample of the population', British Medical
Journal, vol. 2, 1956, p. 904.
11 College of General Pactitioners, 'Chronic bronchitis in Great Britain', British
12 V.A. Getting et al., 'Evaluation of a method of self-testing for diabetes', Diabetes,
vol. i, 1952, p. 194.
13 R.E. Tunbridge, 'Sociomedical aspects of diabetes mellitus', Lancet, vol. 2, 1953,
P- 893-
14 I. Redhead, 'Incidence of glycosuria and diabetes mellitus in a general practice',
British Medical Journal, vol. I, 1960, p. 695.
15 J.B. Walker & D. Kerridge, Diabetes in an English community, Leicester University
Press, 1961.
16 J. Harkness, 'Prevalence of glycosuria and diabetes mellitus: a comprehen-
sive survey in an urban community', British Medical Journal, vol. I, 1962,
P- 'SOS-
17 Report of a working party appointed by the College of General Practitioners, 'A
diabetes survey', British Medical Journal, vol. i, 1962, p. 1497.
18 See, for example, 'Diabetes survey: Bedford 1962', Proceedings of the Royal Society
of Medicine, vol. 57, 1964, p. 193.
19 R. Doll et al., 'Occupational factors in the aetiology of gastric and duodenal
ulcers', Special Report Series of the Medical Research Council, no. 276, London,
HMSO, 1951.
20 A.M. Stewart & J.P.W. Hughes, 'Mass radiography findings in the Northamp-
tonshire boot and shoe industry, 1945-6', British Medical Journal, vol. i, 1951,
P- 899-
21 See, for example, W.E. Miall et al., 'An epidemiological study of rheumatoid
arthritis associated with characteristic chest x-ray appearances in coal-workers',
Notes 139
22 M. Hamilton, G. Pickering et al., 'The aetiology of essential hypertension',
Clinical Science, vol. 13, 1954, p. n.
23 J.N. Morris, Uses of epidemiology.
24 Ibid, p. 70.
25 LJ. Wilts (ed.), Medical surveys and clinical trials, London, Oxford University
Press, 1959.
26 Ibid, p. 11.
27 H. Keen, 'Presymptomatic diagnosis of diabetes', Proceedings of the Royal Society of
Medicine, vol. 59, 1966, p. 1169.
28 Ibid.
29 K. Faber, Nosography in modern internal medicine, London, Oxford University Press,
'923-
30 F.G. Crookshank (ed.), Influenza: essays by several authors, London, Heinemann,
1922.
31 L.S. King, 'What is disease?', Philosophy of Science, vol. 21, 1954, p. 194.
32 W. Riese, The conception of disease: its history, its versions and its nature, New York,
Philosophical Library, 1953, p. 89.
33 J.A. Ryle, Changing disciplines, London, Oxford University Press, 1948.
34 Ibid.
35 H. Cohen, 'The evolution of the concept of disease', Proceedings of the Royal Society
of Medicine, vol. 48, 1955, pp. 162, 167.
36 M. Hamilton et al., 'The aetiology of essential hypertension'.
37 G. Pickering, 'Logic and hypertension', Lancet, vol. 2, 1962, p. 149.
38 M. Hamilton et al., 'The aetiology of essential hypertension'.
39 Ibid.
40 J. McMichael, 'Logic and hypertension', Lancet, vol. 2, 1962, p. 99.
41 'Diabetes survey: Bedford 1962', Proceedings of the Royal Society ofMedicine, vol. 57,
1964, p. 193.
42 See, for example, L. Breslow, 'Multiphasic screening in California', Journal of
Chronic Diseases, vol. 2, 1955, p. 375; and M.L. Levin, 'Screening for asympto-
matic disease', Journal of Chronic Diseases, vol. 2, 1955, p. 367.
43 See, for example, RJ. Donaldson & J.M. Howell, 'A multiple screening clinic',
44 Screening in medical care: reviewing the evidence, London, Nuffield, 1968.
45 WJ.H. Butterfield, Priorities in medicine, London, Nuffield, 1968.
46 J.N. Morris, Uses of epidemiology (2nd edn).
47 J.N. Morris, Uses of epidemiology (1st edn), p. 66.
48 J.A. Ryle, 'Aetiology: a plea for wider concepts and new study', Lancet, vol. 2,
1942, p. 29.
49 Ibid.
50 R. Muir, Textbook of pathology, London, Arnold, 1933 (3rd edn).
51 Ibid.
52 Ibid (6th edn), 1951.
53 Ibid (sth edn), 1941.
54 Ibid.
55 Ibid.
140 Notes
56 J.A. Ryle, 'Aetiology: a plea for wider concepts'.
57 E. Durkheim, Elementaryforms ofthe religious life, London, Alien and Unwin, 1933.
58 J.A. Ryle, 'Aetiology: a plea for wider concepts', p. 30.
59 D. MacKay, Hospital morbidity statistics: studies on medical and population subjects,
London, HMSO, 1951.
Chapter II
1 T. McKeown, Medicine in modern society, London, Alien and Unwin, 1965, p. 177.
2 Report of the Committee on Child Health Services, Fitfor the future (Court
Report), London, HMSO, 1976.
3 See, for example, Editorial, 'General practitioners and psychiatrists - a new
relationship?', Journal of the Royal College of General Practitioners, vol. 28, 1978,
p. 643.
4 See, for example, L. Kanner, 'Trends in child psychiatry', Journal of Mental
Science, vol. 105, 1959, p. 581.
5 See, for example, papers by T.H.D. Arie & M. Roth, in G. McLachlan (ed.),
Approaches to action: a symposium on servicefor the mentally ill and handicapped, London,
Nuffield, 1972.
6 Report of the Inter-Departmental Committee on Medical Schools (Goodenough Report),
London, HMSO, 1944.
7 Ibid, p. 140.
8 Ibid, p. 157.
9 Report of the Royal Commission on Medical Education (Todd Report), London,
HMSO, 1968.
10 Ibid, p. 11.
11 A.D. Frazer, 'The problem of the defaulter', British Journal of Venereal Diseases,
vol. 8, 1932, p. 56.
12 Ibid. p. 58.
see part m.
14 Hanschell, H.M. 'The defaulting seaman', British Journal of Venereal Diseases, vol.
11, 1935, p. 28.
15 H. Nichol, 'The defaulting prostitute', ibid, p. 31.
16 H. Nichol, 'The defaulting travelling man', ibid, p. 98.
17 D. Nabarro, 'The defaulting child', ibid, p. 91.
18 W.V. McFarlane & H.M.Johns, 'The problem of default in a venereal diseases
clinic: a medico-social analysis of 381 women patients', British Journal of Venereal
Diseases, vol. 23, 1947, p. 171.
19 P. Ley, 'Towards better doctor-patient communications', in A.E. Bennett (ed.),
Communication between doctors and patients. London, Nuffield, 1976.
20 Ibid, p. 82.
22 L. Cole, 'Prognosis and the patient', Lancet, vol. i, 1946, p. i.
23 T.G. Armstrong, 'The use of reassurance , Lancet, vol. 2, 1946, p. 480.
24 J. Parkinson, 'The patient and the physician', Lancet, vol. 2, 1951, p. 457.
Notes 141
25 A. Meares, 'Communication and the patient', Lancet, vol. i, 1960, p. 663.
26 Joint Sub-Committee of the Standing Medical and Standing Nursing Advisory
Committees for the Central Health Services Council, Communication between
doctors, nurses and patients: an aspect of human relations in the hospital service, London,
HMSO, 1963.
27 Ibid, p. 7.
28 Editorial, 'Human relations in hospital', Lancet, vol. 2, 1963, p. 77.
29 A. Cartwright, Human relations and hospital care, London, Routledge and Kegan
Paul, 1964.
30 C.M. Fletcher, Communication in medicine, London, Nuffield, 1973.
31 Ibid, p. 17.
32 H.B. Brackenbury, Patient and doctor, London, Hodder and Stoughton, 1935,
p. 72.
33 F. Honigsbaum, The division in British medicine, London, Kogan Page, 1979,
p. 146.
34 H.B. Brackenbury, Patient and doctor, p. 74.
35 Ibid, p. 77.
36 Ibid, p. 109.
37 Ibid, p. 100.
38 M.P. Raven, 'Medicine as an art', Lancet, vol. 2, 1932, p. 602.
39 C.M. Campbell, 'The GP's approach to his nervous and mental patients', British
40 H. Crichton-Miller, 'Primitive man and the modern patient', British Medical
Journal, vol. 2, 1932, p. 430.
41 E.Jones, 'The unconscious mind and medical practice', British Medical Journal,
vol. i, 1938, p. 1354.
42 H. Lett, 'The entrance into medicine', British Medical Journal, vol. I, 1939,
p. 1190.
43 M. Cassidy, 'Doctor and patient', Lancet, vol. i, 1938, p. 175.
44 E.D. Wittkower, 'Psychological aspects of venereal disease', British Journal of
Venereal Diseases, vol. 24, 1948, p. 59.
45 Ibid, p. 62.
46 R. Sutherland, 'Some individual and social factors in venereal disease', British
Journal of Venereal Diseases, vol. 25, 1950, p. i.
47 Planning Committee of the Royal College of Physicians, Report on medical
education, London, RCP 1944.
48 Ibid, p. 22.
49 Ibid, p. 25.
50 Ibid, p. 31.
51 J. Spence, 'The need for understanding the individual as part of the training and
function of doctors and nurses', 1949 lecture. Reprinted inj. Spence, The purpose
and practice of medicine, London, Oxford University Press, 1960.
52 H. Cairns, 'The student's objective', Lancet, vol. 2, 1949, p. 665.
53 M. Balint, 'The doctor, his patient and the illness', Lancet, vol. i, 1955,
p- 683.
54 M. Balint, The doctor, his patient and the illness, London, Pitman, 1956.
142 Notes
55 K.A.J. Jarvinen, 'Can ward rounds be a danger to patients with myocardial
infarcation?', British Medical Journal, vol. i, 1955, p. 318.
56 R.M. Ellison, 'Strained relations', Lancet, vol. 2, 1955, p. 1330.
57 A.E. dark-Kennedy, 'Medicine in relation to society', British Medical Journal,
vol. i, 1955, p. 619.
58 H.L. Rogerson, 'Venereophobia in the male', British Journal of Venereal Diseases,
vol. 26, 1951, p. 158.
59 Venereologists Group Committee, 'Social work in the venereal disease service',
British Journal of Venereal Diseases, vol. 28, 1952, p. 146.
60 G.O. Home, 'The contemporary defaulter in the venereal disease clinic-further
observations', British Journal of Venereal Diseases, vol. 29, 1953, p. 210.
61 J. O'Hare, 'The road to promiscuity', British Journal of Venereal Diseases, vol. 36,
1960, p. 122.
62 Ibid, p. 124.
63 K. Browne & P. Freeling, 'The doctor-patient relationship', Practitioner, vol.
196, pp. 168, 316, 454, 730, 868 vol. 197, pp. 112, 252, 1966.
64 K. Browne & P. Freeling. The doctor—patient relationship, London, Churchill
Livingstone, 1967.
65 Ibid, p. i.
66 The future general practitioner, London, Royal College of General Practitioners,
1972.
67 P. Hopkins, Patient-centred medicine, London, Regional Doctor Publication, 1972.
68 R. Hutchison & H. Rainy, Clinical methods, London, Cassel, 1897 (ist edn).
69 R. Hutchison & D. Hunter, Clinical methods, London, Cassel, 1949 (i2th edn).
70 R. Bomford et al., Hutchison's clinical methods, London, Bailliere Tindall, 1975
(i6th edn).
71 Ibid.
72 M. Foucault, Discipline and punish, p. 192.
73 See, for example, W.R. Arney, Power and the profession of obstetrics, Chicago
University Press, forthcoming.
74 C. Gordon (ed), Alichel Foucault: power/knowledge, Brighton, Harvester, 1980,
p. 96.
Chapter 12
P- '93-
2 T. Parsons, The social system, New York, Free Press, 1951, chapter 10.
3 H. Brackenbury, Doctor and patient, London, Hodder, 1935.
4 E. Freidson, 'Dilemmas in the doctor-patient relationship', first published in
1961. Reprinted in A.M. Rose (ed.), Human behaviour and social processes, London,
Routledge and Kegan Paul 1962.
5 T. Szasz & M. Hollander, 'The basic models of the doctor-patient relationship',
Archives of Internal Medicine, vol. 97, 1956, p. 585.
6 M. Balint, The doctor, his patient and the illness, London, Pitman, 1956.
Notes 1 43
7 E. Freidson, Profession of Medicine, New York, Dodds Mead, 1970.
8 K. Browne & P. Freeling, The doctor—patient relationship, London, Churchill
Livingstone, 1967.
9 G. Stimson & B. Webb, Going to see the doctor, London, Routledge and Kegan
Paul, 1975.
10 E. Rubington & M.S. Weinberg, Deviance: the inter-actionistperspective, London,
Collier-Macmillan, 1968.
11 G. Stimson & B. Webb, Going to see the doctor, p. 8.
12 See, for example, M. Wadsworth & D. Robinson, Studies in every-day medical life,
London, Martin Robertson, 1976.
13 N. Jewson, 'Disappearance of the sick-man from medical cosmologies, 1770
1870', Sociology, vol. 10, 1976, p. 225.
14 K. Figlio, 'The historiography of scientific medicine', Comparative Studies in Society
and History, vol. 19, 1977, p. 262.
15 C. Gordon (ed.), Michel Foucault: power/knowledge, Brighton, Harvester, 1980,
P- 239-
16 Ibid. p. 58.
Index
air, 16, 17 health care, comprehensive, 33, 100

anatomical atlas, 1-2,5,6 health care team, 83-4,88
anthropology, 113 health centres, 32,36-8,82-4
anti-psychiatry, 71 hospital almoner, 39
hygiene, 35
Balint,6g, 81, 108 mental, 26, 75,106
borderline, 48,66,97 school, 16
social, 10-13
causality, 98 100 hygiology, 38
Census, 42 hypertension, 96
child, 13-16,26-7,37,54-63, 111, 114
childbirth, 15, in illness behaviour, 37,80
clinical examination, 2,3, 36,102,103,108 illness
clinical iceberg, 37 chronic, 52,77,87,114-15
clinical science, 43 5 minor, 77, 79,81,84
communication, 71,103 5 infant mortality, 15
community care, 100,111 insanity, 19-22, 26, 30
compliance, 104 Institute of Social Medicine, 52,53,56
comprehensive health care, 33, 100 institutionalisation, 71
confession, 25, 113-14, 117
coping, 22, 72,88 Kuhn, 76
controlled trial, 44-6
Court Report, 62, 101 labelling, 71
Dawson Report, 32-5,36,82 Mass Observation, 49

decarceration, 67 mass society, 40
default, 103-4, I09 medical education, 23,39-40,69, 102,108
diabetes, 94-5 mental deficiency, 64-5
doctor-patient relationship, 101-12, 115 McKenzie, 75
Durkheim,99, 113
National Health Insurance, 34
epidemiology, 46-7,93 national health service, 111
examination (clinical), 2, 3,36, 102, 103, natural history, 45,86
108 neurasthenia, 20,21, 22,69-70
exercise, 34 5 neurology, 20, 21-2,68
nosography, 95-6
Freud, 21-2,24, 25,30
open-door policy, 67
Gesell, 60
gerontology, 90 physical culture, 34-5
Goodenough Report, 39,93, 102, 107 Pickles, 47, 75
growth and development, 56-63 Pioneer health centre, 36-8, 75,80, 82
145
146 Index
placebo, 45 school medical service, 15-16
psychoanalysis, 21,25 screening, 36,97 8
psychology, 113-14 Sheldon,85,gi
child, 27,60 shock treatment, 67
clinical, 30 social control, 5,9,29,51,116-17
educational, 27 social medicine, 38-41,52
individual, 24 socialism, 40
industrial, 28 sociology, 54,113-16
medical, 29, 106 stigma, 71
normal, 23-4 stress, 22, 72
prevention, 35,36,38,40,88 specialisation, 54, 73-4, 101-2
public health, 10, 38,55,93 subjectivity, 71,110,112,114, 116
records, 8, 15,33-4,37,47-8,76 Tavistock Clinic, 25,30

reductiomsm, 73 temporal gaze, 18, 74-5,86-7
rehabilitation, 70,87 therapeutic community, 71
relational medicine, 44 tuberculosis, 7,11-12,16,46,98-9
repression, 5, 12,29, i r 7
Royal Commissions on
lunacy, 24,29,30 venereal disease, 12-13, '8,103-4, '°7,
medical education, 69,102 100-9
venereal disease, 12
War-time Social Survey, 49-50,75
sample survey, 53 whole-person medicine, 106

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Political anatomy of the body

Medical knowledge in Britain in the twentieth century

CAMBRIDGE UNIVERSITY PRESS

© Cambridge University Press 1983

First published 1983

Printed in Great Britain at

Library of Congress catalogue card number: 82-9546

British Library cataloguing in publication data

I am grateful for the guidance and encouragement of Margot Jefferys who

I doubt if it ever occurred to me or my fellow medical students that the

The anatomical atlas stands between ignorance and medical knowledge.

appearance, the old languages, the ancient ways of seeing, disappeared. In

occurred in the regime of criminal punishment: from being subjected to

various disciplines of the individual, there lies an imprint of a body which

In 1887, following the failure of the citizenry of Edinburgh to found a

An extended medical gaz.e

the social configuration of their relationships. The Dispensary was a device,

by Newman, depended on an educated people 'willing and able to practice

which brought people into contact, became an item of medical record. It

The child as object and problem

observation. In effect, the milk depot functioned as a surveillance

Social space and social time

'debilitated, undernourished children, those with incipient pulmonary

Similarly, the Dispensary did not localise pathology. A single patient

In 1906 Bruce published his Studies ofclinical psychiatry-a standard textbook

Insanity and neurasthenia

categories - cholorosis, anaemia, even malingering - had been used

Medicalisalion of the mind

The Tavistock Clinic, together with its associated Institute of Medical

social, it is necessary to be nominalist. The social was created by a gaze

'[children's] abnormalities are as unshaped as their normalities and they

accordance with the best principles of mental hygiene.'68 As early as 1919,

treatment, to raise many from lower to higher classes ... practical

A new psychological medicine

In 1920 the Consultative Council on Medical and Allied Services of the

Comprehensive health care

The Pioneer health centre

Peckham, individual bodies and their relationships yielded to a clearer field

quickly engendered that the Royal College of Physicians appointed a Social

The normal control

The clinical science campaign, which, from 1930 onwards,was actively

believe that 'a similar variability may be demonstrated or assumed in

developed by companies in the British Association of Chemical Manufac-

Surveillance by the survey

legislation but also in watching the effects of totalitarian war on the

constant information about the extent - and changes - of illness in the

In establishing a new political economy of power the Panopticon had

An interest in diseases of children had been shown by some general

In establishing a new political economy of power the Panopticon had

An interest in diseases of children had been shown by some general

In 1942 the Executive Committee of the British Paediatric Association

Problems of the normal child

The 'problems of the normal child' would have been a contradiction in

In 1965. reflecting on the history of paediatrics, the President of the

The paediatric principle

In 1924, Newman, the Chief Medical Officer of the Board of Education -

investigations in a number of areas'.4 Six areas were chosen of such varied

Information has established that group feeling is a medico-psychological

Normalisation of the psychiatric patient

The fabrication of subjects

though it was uncommon among healthily reared young country women.

The changes in medicine which occurred at the end of the eighteenth

prenatal influences, the effects of wrong habits in childhood, the final